
Class J^CSO 

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COPYRIGHT DEPOSIT 



A SYNOPSIS OF 
MEDICAL TREATMENT 



BY 

GEORGE CHEEVER SHATTUCK, M.D. 
Assistant Physician to the Massachusetts General Hospital 



SECOND EDITION 
REVISED AND ENLARGED 

(Second Printing-) 



*f? 



BOSTON: 

W. M. LEONARD, Publisher 

1915 






COPYRIGHT 
BY 

W. M. LEONARD 

1915 



4' 



■:■ i 



<S>CLA414577 
NOV 15 1915 



AU> y( 



TO 

WILLIAM HENRY SMITH, M.D. 

TEACHER IN MEDICINE 

AND 

FRIEND TO MANY 



CONTENTS AND INDEX. 



PAGE 

Preface 10 

CHAPTER I. 
CARDIAC INSUFFICIENCY. 

Principles of Treatment 11 

Methods of Treatment: — 

( a ) Rest 11 

( o ) Depletion 11 

(c) Stimulation 15 

(d) Diet 17 

(e) Regulation of Mode of Life 17 

Valvular Disease: — 

Classification of Valvular Disease 19 

Pathology and Diagnosis 19 

Treatment for: — 

I. Congenital and Obsolete Infectious Valve 

Lesions 21 

II. Active Infectious Lesions 21 

III. Syphilitic Valve Lesions 25 

IV. Degenerative Valve Lesions 25 

Hypertension with Cardiac Insufficiency . .. 25 

Acute Pulmonary Edema with Hypertension 27 

Pulmonary Edema without Hypertension . ... 29 

Circulatory Disorders in the Infectious Diseases: — 

Cardiac Disorders 31 

Vascular Relaxation, "Vasomotor Paresis" 33 

Angina Pectoris: — 

Classification 35 

Diagnosis 35 

4 



Syphilitic Angina: — 
Treatment in General 
Treatment of Attack 



Degenerative Angina: Treatment 
Embolic Angina: Treatment. . . . 
Neurotic Angina: Treatment... 



CHAPTER II. 

NEPHRITIS. 

Classification 

Differentiation of Types 

Acute Renal Irritation: Treatment. 



Acute Nephritis: — 

Principles of Treatment. 
Methods of Treatment: — 

Sweating 

Purgation 

Diet 

Liquids 

Nutrition 

Medication 

Prophylaxis 



Chronic Nephritis: — 

Principles of Treatment 

Methods of Treatment 

Syphilitic Nephritis 

Arteriosclerotic Degeneration : Treatment 
Passive Congestion: Treatment 

Uremia : — 

Methods of Treatment 



CHAPTER III. 
ACUTE INFECTIOUS DISEASES. 
Principles of Treatment 



Typhoid Fever. 

Principles of Treatment 

Routine Orders 



PAGE 



37 
39 



39 
41 

41 



43 

45 
49 

49 

49 
51 
51 
53 
53 
53 
53 

55 
55 

57 
57 
57 

59 



63 



65 
65 



6 

PAGE 

Methods of Treatment: — 

Prophylaxis 67 

Dilution and Elimination of Toxins 69 

Conservation of Strength 69 

Diet 69 

Medication 71 

Observation 71 

Convalescence 73 

Nursing 73 

Symptomatic Treatment : — 

Fever and Toxemia 75 

Circulatory Weakness 79 

Diarrhoea 79 

Constipation 79 

Distention 81 

Vomiting 81 

Headache 81 

Complications, Treatment of: — 

Hemorrhage 81 

Perforation 83 

Rheumatic Fever. 

Principles of Treatment 83 

Methods of Treatment 83 

Lobar Pneumonia. 

Principles of Treatment 89 

Methods of Treatment 89 

Stimulation of Heart 91 

Delirium : Treatment 93 

Broncho-pneumonia 93 

Acute Inflammation of the Upper Respiratory Tract. 

Etiology 93 

Complications and Sequell^: 95 

Diagnosis 95 

Prophylaxis 95 

Treatment Applicable in General 95 



7 

PAGE 

Acute Pharyngitis : Treatment 97 

Coryza : Treatment 99 

Acute Tonsillitis: Treatment 99 

Acute Laryngitis: Treatment 101 

Acute Tracheitis : Treatment 101 

Bronchitis, Acute: Treatment 103 

Bronchitis, Chronic: Treatment 105 

Bronchiectasis: Treatment 105, 107 

CHAPTER IV. 
GASTRIC AND DUODENAL ULCER. 

Indications for Medical Treatment 109 

Principles of Treatment 109 

Methods of Treatment 109 

Diet Lists 109-113 

Complications, Treatment of: — 

Hemorrhage 113 

Perforation 115 

Pyloric Obstruction 115 

Persistent Severe Symptoms 115 

Acute Gastritis and Gastro-enteritis. 

Diagnosis 119 

Principles of Treatment 119 

Methods 119 

Simple Diarrhoea. 

Diagnosis 123 

Principles of Treatment 125 

Methods of Treatment 125 

Medication 127 

Constipation. 

Classification 127 

Principles of Treatment 129 



Methods : — 

Obstructive Constipation 129 

Spasmodic Constipation 129 

Atonic Constipation 133 

Various 133 



CHAPTER V. 

Foreword 137 

Abbreviations 139 

SYNOPSIS OF DRUGS. 

Important Drugs: 

1. Salvarsan and Neosalvarsan 139, 143 

2. Mercury 147 

3. Iodide of Potash 149 

4. Diphtheria Antitoxin 151 

5. Morphine 153 

6. Digitalis 157 

7. Nitroglycerin and Nitrites 159 

8. Theobromine 161 

9. Magnesium Sulphate and Other Purgatives.. 163 

10. Quinine 165 

11. Salicylate . 167 

12. Hexamethylenamine 169 

Valuable Drugs and Non-medicinal Preparations: 

13. Blat id's Pill 169 

14. Trional 171 

15. Bromide 171 

16. Phenacetin 171 

17. Dover's Powder 173 

18. Codeine 173 

19. Sodium Bicarbonate 173 

20. Bismuth 173 

21. Calomel 175 

22. Castor Oil 175 

23. Cascara 175 



PAGE 

24. Vaccine Virus 175 

25. Typhoid Vaccine 177 

26. Tuberculin 177 

27. Normal Salt Solution 177 

28. Alcoholic Beverages 179 

29. "Russian Oil" 179 

30. Agar-Agar 181 

Drugs Valuable for Occasional Use: 

List of : 181 

Drugs in Common Use: 

List of: 183 

Tables of Weights and Measures 185 



PEEFACE. 



This work represents an attempt to offer clearly and 
concisely sound principles of treatment based on known 
pathology. The methods described are selected from those 
that have been tried at the Massachusetts General Hospital 
or in private practice. Most of them have been taught 
by Prof. F. C. Shattuck, Dr. William H. Smith or others on 
the staff of the Hospital or of the Harvard Medical School. 
It is not to be supposed that any of these men subscribe 
fully to everything here set forth or that further advance 
will not require revision. 

The writer wishes here to express his deep appreciation 
of the debt which he owes to his teachers in medicine, of 
their kindliness to their pupils and of their humanity to 
their patients. 

Brevity being essential to the writer's purpose, this 
synopsis is necessarily incomplete. The book was prepared 
primarily for use in the Harvard Medical School. 



PREFACE TO SECOND EDITION. 



In this edition, as in the first, completeness has been 
sacrificed for brevity, but new material has been added and 
many changes have been made. 

More reliance than before has been placed on personal 
experience, but the information about salvarsan was de- 
rived, chiefly, from recent literature. 

It is a pleasure to acknowledge the assistance and help- 
ful criticism of friends and, notably, that of Mr. Godsoe, 
Pharmacist of the Massachusetts General Hospital. 

G. C. S. 
Note. 

In this printing errors have been corrected and minor 
changes and additions have been made. 

The names of unofficial drugs have been spelled as in the 
Nineteenth Edition of the United States Dispensatory. 

10 



CHAPTER I. 



CARDIAC INSUFFICIENCY. 

GENERAL PRINCIPLES OF TREATMENT. 

A. Rest. 

B. Depletion. 

C. Stimulation. 

D. Suitable Diet. 

E. Regulation of Mode of Life. 

The principles are much the same whatever the under- 
lying cause. Treatment must, however, be regulated to 
suit the severity of symptoms, to meet individual needs, 
and for varieties of disease. 

An exact diagnosis may be difficult in the presence of 
severe insufficiency and may not be necessary at first, but 
accuracy in diagnosis is very important for prognosis' and 
for planning treatment for the future. 

METHODS OF TREATMENT. 
A. Rest. 

1. Semirecumhent position in bed or chair. 

2. Minimum exertion. 

3. Relieve discomfort and secure sleep. If there is much 

discomfort morphine subcutaneously is indicated. 

B. Depletion. 
1. Purgation. Obtain watery catharsis more or less pro- 
fuse according to amount of edema. 
When edema is absent or slight avoid excessive purgation 
lest exhaustion result. 
Magnesium sulphate (p. 163) is useful as a purgative. 
11 



13 



2. Limitation of Liquids. Total liquids, including liquid 
foods, should not exceed three pints in twenty-four hours. 
One pint in twenty-four hours is near the minimum. The 
patient should not be allowed to suffer from thirst. 
It may be relieved by sucking cracked ice or by gar- 
gling. 

3. Diuresis should follow the use of digitalis. In mild 
cases of insufficiency, rest, purgation and limitation of 
liquids with or without digitalis may suffice. 

When edema is persistent or extreme, diuretics should be 
prescribed. Theobromine (p. 161) or its substitutes may be 
expected to act well provided the kidneys are not severely 
damaged. Calomel should not be given if the patient 
has nephritis because salivation may result. Apocynum, 
theocine or theophylline may act better than theobromine 
in some cases. 

4. Venesection. Indicated occasionally when there is 
engorgement of the right ventricle with marked evidence 
of venous stasis; e.g. dyspnoea, cyanosis, pulmonary 
edema and engorgement of neck-veins and liver. 

A pint of blood or even more may be withdrawn. Vene- 
section is contraindicated by emaciation or by marked 
weakness or anemia. Blood is generally withdrawn by 
incising a vein on the inner side of the elbow. A tourni- 
quet may be put around the arm to render the veins prom- 
inent. The incision should be made in the long axis of the 
vein with the point of a sharp knife. The bleeding can be 
stopped with a pad and bandage. Suturing the vein is un- 
necessary. 

5. Leeching. Useful as a substitute for venesection 
when the latter would be undesirable or when symptoms 
are less severe. Leeching will generally relieve painful 
engorgement of the liver. 

Apply a dozen leeches over the right hypochondrium 
and allow them to remain until they drop off. The abdo- 
men should then be covered with a large, moist, absorbent 
dressing to favor oozing from the bites. A drop of milk 
placed on the skin encourages the leech to bite. Salt 
causes him to let go. 



15 



6. Tapping. Necessary when fluid in the chest or ab- 
dominal cavity seriously embarrasses the heart or respira- 
tion. 

C. Stimulation. 

Digitalis (p. 157) is the best cardiac stimulant (other 
drugs may be preferred occasionally). A good tincture of 
digitalis ordinarily acts well. If after pushing digitalis no 
effects are apparent the preparation is probably bad. 
When given by mouth in sufficient dosage its action should 
be apparent in from twenty-four to forty-eight hours. 
When quicker results are needed an initial dose of 30 min. 
(or 2 c.c.) may be injected into the gluteal muscle. 

When prompt effects are desirable digipuratum (p. 159) 
can be used. When given by mouth it should act in from 
twelve to twenty-four hours. Digipuratum-solution in- 
jected intramuscularly may show effects in from I to 1 
hour. It acts more quickly when used intravenously. For 
very urgent insufficiency strophanthin may be used in- 
travenously. It is dangerous (p. 159). 

Caffeine sodio-salicylate is believed to promote diuresis 
when used in conjunction with digitalis. For this purpose 
the caffeine should be used subcut. in repeated doses of 
from 1 to 3 grs. (or 0.06 to 0.2 gm.). 

Black coffee or caffeine citrate may be tried by mouth. 
Caffeine may cause restlessness or insomnia. 

Slight exacerbations of dyspnoea or distress can often be 
relieved by a quickly diffusible stimulant, e.g.: 

By mouth: 

(a) Spiritus ammonia? aromaticus: 1 drach. (or 4 
c.c). 

(&) Spiritus a^theris compositus, " Hoffmann's ano- 
dyne: " 1 drach. (or 4 c.c). 

(c) Whiskey or brandy: from * to 1 oz. (or 15 to 
30 c.c). 

Subcutaneously: 

((?) Whiskey, brandy or ether: 1 drach. (or 4 c.c). 

Inject intramuscularly. 



17 

(e) Camphor in cil: * 3 grs. (or 0.2 gm.). Inject 
intramuscularly. 

(/) Cocaine hydrochloride: from | to 1 gr. (or 
0.008 to 0.016 gm.). It is said to be dan- 
gerous but may act very well. 

Insufficiency with much pain requires morphine (p. 153). 
It seems to act under these circumstances as an efficient 
cardiac stimulant. It brings also physical comfort and psy- 
chic relief which favor recuperation. The morphine should 
be used subcut. under these circumstances to ensure prompt 
effect. 

D. Diet. 

Spare the patient unnecessary effort, particularly if there 
is much dyspnoea, by ordering food which is easy to swallow 
and which requires no chewing. 

By frequent small feedings and by avoiding gas-producing 
foods seek to prevent cardiac embarrassment from disten- 
tion. 

Emaciated patients should take as much concentrated 
nourishment as is practicable in order to strengthen the 
heart muscle by improved nutrition. 

Fat or plethoric individuals may benefit by relative star- 
vation. 

E. Regulation of Mode of Life. 

To prevent relapse during and after convalescence, the 
mode of life of the patient must be wisely regulated; and 
intelligent cooperation between patient and physician is es- 
sential to this end. It is generally necessary to tell the 
patient something about his condition and to warn him to 
avoid activities which induce much fatigue and exertions 
which cause much dyspnoea. 

Judgment and caution must be exercised in dealing with 
an apprehensive patient lest danger be exaggerated in his 
mind, and harm result. After a sufficient period of com- 
plete rest the patient should be encouraged to take regular 



Should be specially prepared for subcut. use. 



19 

exercise within the limits of tolerance in order to 
strengthen the heart by promoting hypertrophy. 

Exercise and work should be resumed very gradually 
under close supervision. 

CLASSIFICATION OF VALVULAR DISEASE. 

rMost commonly discovered in 

1. Congenital . . j ear]y cMwhood 

rMost commonly discovered in 

2. Infectious .J ., 

1 youth. 

„ „ , ..... rMost commonly discovered in 

3. Syphilitic . J ._,, ... 

1 middle life. 

, _ .. rMost commonly discovered in old 

4. Degenerative . J 

| age. 

NOTES ON PATHOLOGY AND DIAGNOSIS. 

1. Congenital lesions. Pulmonic stenosis is the most 
common. It is seldom mistaken for other types of lesion 
but may easily be confused with anomalies which have sim- 
ilar signs and which are often combined with it. 

2. Infectious lesions: 

(a) Active stage. Inflammation of valves due to pres- 
ence of bacteria on the valve. 

(b) Obsolete stage. Valves deformed and scarred as a 
result of inflammation. 

(c) Recurrent stage. Reinfection with inflammation 
at site of old lesion. 

Lesions are found commonly at the mitral valve or at the 
aortic and mitral valves, seldom at the aortic valve alone. 
Occasionally the mitral, aortic and tricuspid valves are all 
diseased. Stenosis develops frequently. 

Obsolete lesions if well compensated may give no symp- 
toms. They first attract attention by diminished cardiac 
efficiency or by failure of compensation. 

In the active or recurrent stage the symptoms are those 
of general infection with or without failure of compensa- 
tion. 

3. Syphilitic lesions. The lesion generally begins in the 
ascending aorta and extends subsequently to the aortic 



21 



valve. The earliest signs may be slight dilatation of the 
arch and the murmur of aortic roughening. Later, that of 
aortic regurgitation may appear and, finally, relative mitral 
regurgitation may develop. 

A lesion of the aortic valve only, in a young adult, sug- 
gests syphilis as its cause. Aneurism or coronary endar- 
teritis may coexist as part of the same process. 

Evidence of an old syphilis supports the diagnosis. 

4. Degenerative lesions. As in syphilis, the signs point 
to a lesion at the aortic valve but evidence of syphilis is 
lacking. The background is one of senility and general 
arteriosclerosis to which sclerosis of the aorta and of the 
aortic valve is incidental. There may be dilatation of the 
arch and evidence of myocardial degeneration, perhaps also 
angina pectoris. 

Note. — All the types of lesion enumerated above may be 
followed in time by cardiac insufficiency. 

TREATMENT FOR TYPES OF VALVULAR 
DISEASE. 

I. Congenital and Obsolete Infectious Lesions of 
Valves. 

Treat according to tbe general principles given above. 

They must be modified for the individual with re- 
gard to severity, duration, nature and cause of 
symptoms. 

II. Active Infectious Lesions of Valves. 
A. Principles of Treatment. As for acute infections in 
general (p. 23) and for cardiac insufficiency if present. 

1. Rest in bed. 

2. Minimum exertion. 

3. Dilution of toxins. 

4. Elimination of toxins. 

5. Maintenance of nutrition. 

6. Stimulation p.r.n. 

Note. — The infection may be acute, subacute or recur- 
rent. The chief dangers are from toxemia, exhaustion, 
cardiac dilatation or embolism. 



23 



A history of recent preexisting rheumatic fever, chorea 
or tonsillitis strengthens a diagnosis of active endocarditis. 

B. Methods, (a) Good nursing is very important. The 
nurse should promote comfort by attention to details, should 
feed the patient and, whenever possible, spare him exer- 
tion or annoyance. 

(&) To dilute toxins and to favor elimination order 
abundance of liquids. Have intake and output recorded. 
If cardiac dilatation threatens or if there is edema liquids 
must be restricted. 

(c) Feedings should be frequent, the food nutritious, and 
the amount regulated by* digestive power. Liquids and soft 
solids are preferable in severe cases because easy to swal- 
low. 

(d) Stimulants are to be avoided unless clearly neces- 
sary because embolism is to be feared and stimulation 
might favor it. 

(e) Sodium salicylate (p. 161) or aspirin in large doses 
may be tried. Small or moderate doses of salicylate are 
not likely to do good in endocarditis. 

if) Tachycardia may sometimes be reduced by an ice- 
bag placed over the praecordia. 

C. Convalescence. To minimize danger of relapse keep 
the patient in bed and as quiet as possible for weeks or 
months after the pulse and temperature have returned to 
normal. Permanent damage nearly always remains. The 
degree of possible improvement depends on the location 
and extent of the lesions and on the recuperative power 
of the patient. Therefore, guard against strain, and treat 
malnutrition or anemia, if present, to promote hypertrophy 
of the heart. 

D. Prophylaxis, (a) Search for and eliminate all foci 
of infection. 

(&) Diseased tonsils, as a rule, should be removed at the 
first suitable opportunity. It is dangerous to remove them 
when acutely inflamed. 

(c) Warn the patient against exposure and advise him 
to attend promptly to ailments, even if slight, and to avoid 
mental strain, and physical exertion which produces dysp- 
noea or fatigue. 



25 



III. Syphilitic Lesions of Valves require antisyphilitic 
medication as well as general measures for cardiac insuf- 
ficiency. 

Little improvement can be expected, however, unless the 
diagnosis be made before extensive and irreparable damage 
has occurred. 

IV. Degenerative Lesions of Valves may be treated on 
general principles with certain modifications as follows: 

(a) When blood-pressure is high, nitrites may be of 
value to lighten the work of the heart by lowering pressure 
temporarily. 

(b) Thin patients require the maximum nutrition to 
strengthen the heart. They should undergo little or no 
purgation unless edema is considerable. 

(c) Regulation of life is of the utmost importance dur- 
ing and after convalescence. The patients' cooperation 
must be secured. 

(cl) Many of these patients should take digitalis and 
salts more or less frequently for long periods or for the rest 
of their lives. The best dosage for the individual can be 
determined only by trial. Several small doses per week 
taken at regular intervals may be sufficient. Warn the pa- 
tient not to be without his medicine or to give it up on 
his own responsibility. The heart muscle may, perhaps, 
be so changed that it cannot respond to any form of treat- 
ment. 

HYPERTENSION WITH CARDIAC 
INSUFFICIENCY. 
Etiology and Symptoms. Hypertension is commonest in 
chronic nephritis and is seen also in arteriosclerosis. The 
hypertension and left ventricular hypertrophy develop 
gradually. Symptoms of insufficiency often increase so 
gradually as to be disregarded by the patient for months. 
The condition of the patient is generally more critical than 
the signs would seem to indicate. Acute pulmonary edema 
is common in these cases. Many of them show signs of 
toxemia attributable to deficient renal elimination. 

Treatment. 1. Methods for cardiac insufficiency (p. 11). 
2. Reduce the work of the heart by lowering blood- 



27 

pressure temporarily unless the urinary output 
falls in consequence. 

(a) Vaso-dilators, e.g., nitroglycerin (p. 159), lower 
blood-pressure temporarily and often promote 
diuresis also. 

(6) Purgation, diuresis, venesection and measures 
tending to relieve toxemia or to improve the cir- 
culation seem to favor if not to cause reduction 
of pressure in hypertension. 

(c) Starvation for a day or marked restriction of food 

for several days may benefit plethoric individu- 
als. It is one of the surest means of lowering 
pressure. Emaciation must be avoided because 
it increases cardiac weakness. 

(d) Relief from psychic strain, e.g., business cares, 

may be followed by a fall in pressure. 

3. When toxemia is present reduce it by: 
(a) Purgation or diuresis. 

(&) Restriction of food, and of proteid in particular, 
(c) Hot-air baths or hot soaks if cardiac symptoms 
permit. 

4. If toxemic symptoms persist after improvement in 

the circulation they are probably uremic in or- 
igin and should be treated accordingly (p. 57). 

ACUTE PULMONARY EDEMA IN 
HYPERTENSION. 

Notes. — Occurs commonly and characteristically in hyper- 
tension. The attack generally follows exertion and may 
not have been preceded by marked symptoms of cardiac 
insufficiency. 

The onset is sudden and alarming. 

The symptoms are severe dyspnoea, cyanosis, wheezing, 
cough, and pinkish, frothy expectoration. There may be 
precordial pain. 

Treatment. Mild attacks may pass off after a little rest. 
Severe attacks require energetic and prompt treatment as 
follows: 

1. Prop the patient up so he can sit upright without 
effort. 



By mouth: 



29 



2. Give morphine sulphate, gr. \ (or 0.016 gm.) atro- 

pine sulphate, gr. T \^ to ^ (or 0.00065 to 0.001 
gm.) and nitroglycerin, gr. T i^ to ^ (or 0.00065 
to 0.001 gm.) subcutaneously at once. 

3. Unless improvement begins promptly, the nitroglyc- 

erin should be repeated, and venesection may be 
performed. 

4. The following drugs may be of service: 

By inhalation: Amyl nitrite: 5 m. (or 0.3 c.c). 

fSpiritus amnionic aromaticus: 1 

drach. (or 4 c.c). 

Spiritus aetheris compositus: * 1 

drach. (or 4 c.c). 

Whisky or brandy: from 4 drach. to 

- 1 oz. (or 15 to 30 c.c). 

_ , , r Cocaine hydrochloride: \ gr. (or 

Subcutaneously: J ___.. fc . ., . . , 

1 0.016 gtii.); said to be dangerous. 

Intravenously: Strophanthin: dangerous (p. 159). 

5. Do not attempt to transport the patient until imme- 

diate danger has passed. 

6. Rest in bed is advisable for a few days to allow the 

heart to recover itself. 

7. Digitalis, purgation, etc., may be needed. 

8. Subsequent regulation of life is essential to avoid 

recurrence. 

Pulmonary Edema without Hypertension. Pulmonary 
edema may appear in cardiac insufficiency from any cause. 
It is common in mitral stenosis, but seldom acute enough 
to require special treatment. When severe it should be 
treated as in hypertension, except, that the blood-pressure 
being normal or low, nitrites are of doubtful value and may 
perhaps do harm. 

Pulmonary edema occurs also in infectious diseases. In 
pneumonia it may be very acute, but is not necessarily of 
cardiac origin. For treatment see p. 31; also "Typhoid 
Fever," pp. 71, 73, and " Pneumonia," p. 91. 



Hoffmann's anodvne.' 



CIRCULATORY DISORDERS IN THE INFEC- 
TIOUS DISEASES. 

Xote. — Common in acute infections, particularly in pneu- 
monia and in septic states. The circulatory disturbances 
may be attributed to one of the following causes or to a 
combination of them. 

A. CAUSES. 

1. Faulty innervation of the heart due to toxemia. 

2. Cloudy swelling of myocardium due to toxemia. 

3. Ill-nourished myocardium secondary to emaciation or 

anemia. 

4. Infection of the valves, myocardium or pericardium. 

5. Lesions obstructing the pulmonary circulation, e.g., 

embolism of the pulmonary artery or of its large 
branches. 

6. Vasomotor relaxation or paresis due to toxemia. 

B. TREATMENT IN GENERAL. 

1. Dilute, eliminate or neutralize toxins. 

2. Minimize exertion. 

3. Prevent abdominal distension. 

4. Strive to maintain nutrition. 

5. Emaciated patients, capable of taking little food, 
sometimes do well on large doses of alcohol which seem to 
act for them as a food and indirectly as a stimulant. 

6. Cardiac stimulants must often be tried empirically 
from lack of a precise diagnosis or as a last hope. They 
often fail to do good. 

C. TREATMENT IN PARTICULAR. 

I. Cardiac Disorders. 

1. Faulty Innervation. Alcohol, digitalis, strychnine or 
ice-bag, etc., may be tried but are not likely to avail much. 

2. Cloudy Swelling. Digitalis, caffeine or camphor may 
be tried. 

3. Ill-nourished Myocardium demands improved nutrition 
of the patient. Alcohol and stimulants may perhaps help. 



33 



4. Cardiac Infection. Treat as for active infectious endo- 
carditis, p. 21. 

5. Obstruction in the Lung. As a rule nothing can be 
done. 

6. Pulmonary Edema occasionally yields promptly to 
atropine, used subcutaneously. Cardiac stimulants or 
strophanthin (dangerous, p. 159) may be tried. Venesec- 
tion may do good if tbe edema be attributable directly to 
cardiac dilatation. 

II. Vascular Relaxation: "Vasomotor Paresis." 

Xotes. — The relaxation is believed to be the result of 
vasomotor paresis produced by the action of toxins on the 
vasomotor center. It occurs occasionally in severe infec- 
tions, particularly in typhoid and in pneumonia. The con- 
dition is analogous to surgical shock although its cause is 
not the same. 

The onset may be gradual or rapid. It can be observed, 
by watching the development, that the pulse becomes weak 
while the heart-sounds are still of good quality. Later, as 
a result of low peripheral pressure and meager return of 
blood to the heart, the heart's action becomes more and 
more rapid, the sounds fainter and perhaps irregular. 
Finally, the extremities become cold, the face pale and the 
pulse imperceptible. 

Principles of Treatment. Promote return of blood to the 
heart by: 

(a) Filling the vessels, or by 
(5) Constriction of vessels. 

Methods: 1. Salt solution used by hypodermoclysis is 
rapidly absorbed and generally acts well in from five to 
fifteen minutes. It may save life even when the patient's 
condition is very bad. A pint, heated to blood-temperature, 
should be used at a time. It may be repeated in an hour 
or later if needed. The administration of frequent doses 
of salt solution in this way may lead to cardiac dilatation 
unless excretion be rapid. 

Salt solution may be given intravenously in very critical 
conditions. 



35 

When the need for salt solution can be anticipated the 
means of administering it should be kept in readiness. 

2. Direct transfusion of blood might be tried if it could 
be done without delay. 

3. Adrenalin chloride is a very powerful vaso-constrictor 
but very transient in its effect. It is difficult to get satis- 
factory results with it. 

Pituitrin has an effect on blood-pressure like adrenalin, 
but milder and less transient. It may be tried safely. 

Caffeine sodio-salicylate, 3 gr. (or 0.2 gm.), may be tried 
subcutaneously, but is not very effective as a vaso-con- 
strictor. 

ANGINA PECTORIS. 

Definition. Pain or distress attributable to spasm, or to 
occlusion, of a coronary artery. 

Spasm is generally associated with syphilitic or degen- 
erative change in the vessel-wall, but lesions may be con- 
fined to other parts of the heart or to the aorta, and 
" neurotic angina," in which there is no known lesion, is 
rather common. Occlusion may be thrombotic or embolic. 

Angina may be indicative of threatened exhaustion or of 
deficient blood-supply to the myocardium. 

Etiological Classification of Angina Pectoris. 

1. Syphilitic: common in men of early middle age. 

2. Degenerative or arteriosclerotic: common in old men. 

3. Embolic: seen in endocarditis or intracardiac throm- 

bosis. 

4. Neurotic: common in young women. 

DIAGNOSIS. 

An accurate history of the mode of onset, duration and 
radiation of the pain and the discovery of an adequate 
background for the disease is of the greatest importance. 
Pain on exertion suggests angina. Angina in a young or 
middle-aged man suggests syphilis. 

A complete physical examination may show nothing im- 



37 



portant. Angina in a young woman suggests psychic 
trauma. 

Painless angina, otherwise typical, is seen rarely. 

I. SYPHILITIC ANGINA. 

Pathology. Syphilitic changes in the aorta, aortic valves 
or coronary arteries, diminishing their circulation are gen- 
erally demonstrable. 

Etiology. A late manifestation of syphilis; commonest 
in middle life. 

Prognosis. The prognosis is very uncertain. 

A. Treatment in General. 

1. Antisyphilitic measures.* 

2. Regulation of life to reduce demands on the heart to 
what it can meet is of the utmost importance. 

(a) Avoid anything known to bring on angina in 

the individual, e.g., exercise after meals. 
(&) Avoid physical and mental strain. 

(c) Avoid distention of the stomach and bowels. 

(d) Food and liquids should be taken in modera- 

tion. 

(e) Tobacco and alcohol in great moderation if 

at all. 

(f) Bowels should be kept free. 

3. Cardiac insufficiency, if present, requires appropriate 
treatment on general principles. 

4. Small doses of digitalis often help to reduce the num- 
ber of attacks even when the usual signs of cardiac in- 
sufficiency are absent. Theobromine sodio-salicylate, grs. 
5 t.i.d., or barium chloride, grs. y 10 t.i.d., may be tried for 
the same purpose. 

5. At the first sign of an attack the patient should take 
nitroglycerin (p. 159) or amyl nitrite, repeat it in a few 
minutes if not relieved and remain quiet for a time after 
the attack has passed. An expected attack can sometimes 
be prevented by timely use of nitroglycerin. The drug 



* It is doubtful whether Salvarsan should he used in the presence 
of severe cardiac disease. 



39 

must be always accessible without effort. Nitroglycerin 
should be chewed and absorbed in the mouth and amyl 
nitrite taken by inhaling it from a handkerchief. It is 
important to provide pearls which break easily but not 
spontaneously if amyl nitrite is to be used. 

B. Treatment of Anginal Attacks. 

If called to treat an attack of angina use nitroglycerin 
subcutaneously or amyl nitrite or both immediately. Repeat 
the dose in a few minutes if the patient is not relieved. 
If nitroglycerin gives no effect in repeated doses amyl 
nitrite may perhaps relieve. If the pain is unusually se- 
vere and obstinate morphine may be injected. 

Do not attempt to transport the patient and do not allow 
him to make the slightest exertion for a time after the 
symptoms have passed. Rest in bed is advisable after a 
severe attack. 

That which is known to bring on an attack must be 
avoided. 

II. DEGENERATIVE ANGINA. 

Pathology. Coronary sclerosis and chronic myocardial 
degeneration, with or without fibrous myocarditis, will 
often be demonstrable as part of a widespread arteri- 
osclerosis. 

Prognosis. Years of life may be possible but sudden 
death may occur at any time. 

Treatment. 1. Regulate life to avoid strain. 

2. When there is any evidence of cardiac insufficiency it 
may be well for the patient to use digitalis and salts for 
long periods. The required dose for the individual should 
be carefully determined by trial. 

3. Digitalis, theobromine or potassium iodide in small 
doses may limit the number of attacks. 

4. If an old syphilis be suspected give potassium iodide 
and protiodide of mercury in moderate doses. 

5. For attacks the treatment is the same as in syphilitic 
angina. 



41 



III. EMBOLIC ANGINA. 

Vaso-dilators are likely to give little relief. Morphine is 
usually required in large doses. (Death may come sud- 
denly at onset of symptoms.) 

IV. NEUROTIC ANGINA. 

Pathology. No characteristic changes recognized. 

Etiology. Commonly due to excess in tea, coffee, or to- 
bacco, to fear or emotional shock and often associated with 
debility. It is seen, almost exclusively, in neurotic young 
women. 

Prognosis. Death is not to be expected and the chance 
of complete cure is excellent. 

Treatment. 1. Remove the cause when possible. 
2. General hygienic measures. 

By these means recurrence can be prevented. 

The attack is generally too brief and mild to require 
treatment, but when severe, it should be treated like or- 
ganic angina. 



CHAPTER II. 



NEPHRITIS. 

CLASSIFICATION. 

1. Acute Renal Irritation."! 

2. Acute Nephritis. L Allied Conditions. 

3. Chronic Nephritis. 

4. Syphilitic Nephritis. 

5. Arteriosclerotic Degeneration. 

6. Passive Congestion. 

NOTES ON CLASSIFICATION. 

This classification aims to separate only the more im- 
portant types of nephritis which can be recognized clin- 
ically and which require different treatment. 

Acute renal irritation, acute nephritis and chronic ne- 
phritis appear to be allied diseases. The gaps between 
them are bridged by intermediate forms and the acute in- 
fectious diseases are responsible for most cases of these 
three types of renal inflammation. Toxic irritation differs 
from acute nephritis mainly in degree, and chronic ne- 
phritis from acute nephritis in that instead of recovering 
it progresses, though it may be slowly. 

Although arteriosclerotic degeneration is essentially dif- 
ferent from chronic nephritis, the latter being primarily 
an inflammation of the kidney and the former being a de- 
generation secondary to vascular disease, the two are often 
combined. In such combinations either process may pre- 
dominate. 

Besides intermediate or mixed forms of nephritis there 
are the rare amyloid degeneration and a variety of forms 
difficult to classify. 

43 



45 



DIFFERENTIATION OF TYPES OF NEPHRITIS. 

Acute Renal Irritation is distinguished from acute ne- 
phritis by less profound changes in the urine, absence of 
symptoms of renal insufficiency and prompt recovery after 
removal of the cause. It is frequently symptomatic in 
acute fevers. 

Acute Nephritis is common in childhood and youth. It 
is generally traceable to an acute infectious disease, is 
often found after scarlet fever and may follow tonsillitis or 
result from an irritant poison. Acute nephritis differs 
much in severity and consequently in signs and symptoms. 
Severe cases may show anuria or marked oliguria with 
anasarca and perhaps uremia. The urine in these cases is 
loaded with blood, albumen, casts and fat, and that of mild 
conditions contains the same elements in smaller amount. 
Blood-pressure may be moderately elevated, and if the dis- 
ease persists for some weeks, left ventricular hypertrophy 
may develop. 

Chronic Nephritis. The etiology is like that of acute 
nephritis, as a rule, but there are some cases arising from 
chronic toxemias. 

Stages. 1. Early. 



_, a. Latent. 

2. Subacute. L Phases. 



f 1). Exacerbation. 



3. Chronic. 

The course of the disease may run from a few years or 
less to twenty years or more. Any stage may be without 
symptoms. The early stage may be indistinguishable 
from acute nephritis, and exacerbations may be mistaken 
for acute nephritis. Left ventricular hypertrophy and 
hypertension develop gradually and there is a progressive 
fall in the specific gravity of the urine associated with an 
increase in the amount of urine. 

The late stage shows marked left ventricular hyper- 
trophy, a blood-pressure generally over 200 mm. of mercury 
and a urine of very low gravity, containing little or no 
albumen and a scanty sediment. At this stage many of 
the glomeruli and much of the parenchyma has been re- 
placed by connective tissue, and shrinkage has followed so 
that the kidneys are much diminished in size. The chief 



dangers are from uremia or from cardiac insufficiency sec- 
ondary to hypertension. In the absence of arteriosclerosis 
a provisional diagnosis of chronic nephritis may often he 
made by the evidence of hypertension and of cardiac hyper- 
trophy. Cases of chronic nephritis complicated with ar- 
teriosclerosis are liable to apoplexy. 

Syphilitic Nephritis is generally regarded as an unusual 
form of acute nephritis. It occurs, according to Osier, most 
commonly in the secondary stage of syphilis within six 
months of the primary lesion and it resembles other toxic 
nephritis. Gumma of the kidney is rarely seen but it is 
probable that some instances of renal arteriosclerosis are 
of syphilitic origin. Signs of an active syphilis in the 
presence of a nephritis suggest but do not prove that the 
two are related. 

Arteriosclerotic Degeneration of the kidney is most com- 
mon in old age. It may be part of a widespread arterio- 
sclerosis or it may be manifested chiefly in the kidney. 
There occurs a non-inflammatory destruction of parts of 
the kidney dependent on sclerosis of the arteries supplying 
those parts. Local shrinkage and irregularity or rough- 
ness of the surface results. 

The urine, at first, may show considerable albumen and 
some blood and casts. Later it resembles that of chronic 
nephritis. Hypertension and left ventricular hypertrophy 
are generally well marked in the later stages of renal de- 
generation. 

The greatest dangers are from cardiac insufficiency or 
cerebral hemorrhage. Typical uremia occurs rarely if at 
all in pure degenerative cases but there is often more or 
less chronic nephritis combined with the degenerative 
lesions. Chronic lead-poisoning, gout or syphilis may be 
important etiologically. 

Passive Congestion is secondary to congestion in the 
venous circulation. Therefore, it is commonly symptomatic 
of cardiac insufficiency. The urine is high colored, scanty 
and of a high gravity. Albumen and casts are found, vary- 
ing in amount and number. There are no definite symp- 
toms, and the urine clears rapidly after removal of the 
congestion. 



49 

Passive congestion may mask an acute nephritis, espe- 
cially in the active stage of endocarditis. 

ACUTE RENAL IRRITATION. 

Treatment. The signs of irritation can be much reduced 
by the free administration of water. The water dilutes the 
irritating substance and promotes excretion by stimulating 
diuresis. No other direct treatment is needed. 

Caution. Make sure that a nephritis is not developing. 

ACUTE NEPHRITIS. 

PRINCIPLES OF TREATMENT. 

A. Reduce the demands on the kidney by: 

1. Rest in bed. 

« ™. • x. i. i r(°) Sweating. 

2. Elimination by other channels. J ,_ , _ 

1 (6) Purging. 

3. Suitable diet. 

4. Limitation of liquids in suitable cases. 

B. Maintain nutrition. 

C. Avoid exposure to cold or to sudden cooling. 

D. Drugs should be used only when indicated; never by 
routine. 

METHODS OF TREATMENT. 

Sweating, 1. Hot-air bath in bed or chair. 

2. Hot tub-bath. 

3. Hot wet pack. 

4. Electric light bath. 

5. Turkish or Russian bath. 

Hot-air baths are best given in bed. If the baths cause 
profuse sweating they may be used daily for an hour or 
more. If sweating does not begin promptly a drink, hot 
or cold, may start it, or pilocarpine may be administered 
subcutaneously. Pilocarpine may cause pulmonary edema 
and is, therefore, contraindicated when the heart is weak, 
the lungs congested, or the patient unconscious. Some 
patients who sweat little at first respond well to subsequent 
baths. 



51 



If sweating cannot be induced, if the pulse becomes 
weak, or if the patient develops cardiac symptoms during 
a bath the baths must be given up. They should not be 
ordered for an unconscious patient without consideration 
followed by close observation. 

FTospitals provide apparatus for the hot-air bath. In 
private houses it can be improvised with barrel-hoops or 
strong wire to arch the bed, an oilcloth from the kitchen 
table as a rubber sheet, an elbow of stovepipe and a 
kerosene lamp to provide the heat; or the patient, without 
clothing, may sit in a cane-bottomed chair under which 
stands a small lamp. Blankets are then wrapped around 
the chair and the patient together, leaving no hole for the 
heat to escape. 

Care must be taken not to set the blankets on fire. 

Purgation. Obtain watery catharsis to reduce edema and 
to increase elimination of toxic material by the intestinal 
tract. Magnesium sulphate, or compound jalap powder 
with additional potassium bitartrate, or elaterium are good 
for this purpose (p. 163). 

In the absence of edema, purgation should not be ex- 
cessive, lest the patient's nutrition suffer. 

Diet. Proteids, meat broths, spices, acids and alcohol 
irritate the kidney and are to be avoided during the acute 
stage. 

Milk is an exception to the rule against proteid because 
experience shows that it is not injurious. A diet exclu- 
sively of milk becomes monotonous if long continued and 
such large quantities are needed to maintain nutrition that 
the fluid part may tend to increase edema.* 

Salt seems not to be harmful as a rule. When, however, 
edema persists in spite of other treatment, a " salt-free " 
diet may be tried, i.e., salt is not to be added to 
food either before or after cooking. This change is fol- 
lowed occasionally by rapid disappearance of the edema. 
If deemed advisable the phosphate f in milk can be pre- 



* Three quarts of milk furnish about 2000 calories which is scaut 
for an adult. 

t One liter of milk contains 3.80 gm. of phosphate and 1.79 gm. of 
chlorides; Sommerfeld, " Handb. d. Milchkunde," p. 271. 



53 

cipitated by adding 5 gr. (or 0.3 gm.) of calcium carbonate 
per pint of milk. 

Diet List (incomplete). Milk, cream, butter, sugar, jun- 
ket, ice cream, bread, toast, cereals, rice, potato, macaroni, 
sago, tapioca, spinach, lettuce, sweet raw fruits or stewed 
fruits. 

In convalescence enlarge diet cautiously on account of 
danger of relapse. When returning to proteid foods allow 
eggs first, then fish and lastly meat, red or white. 

Liquids, including liquid foods, should be limited strictly 
when there is anasarca or when they are not being fully 
excreted. One pint in twenty-four hours may be enough. 
Cracked ice may be used for thirst, but, if the patient 
suffers, more liquid should be allowed. 

Water is an excellent diuretic when freely excreted. It 
dilutes irritating substances and favors their elimination. 

Nutrition. The quantity of food to be prescribed depends 
on the severity of the nephritis, the physical strength, and 
the state of nutrition of the patient. Strong, well-nour- 
ished patients having severe nephritis may benefit by star- 
vation for a clay followed by very small quantities of food 
for several days. A feeble, emaciated and anemic person 
should receive food enough to maintain body-weight. 

Exposure. To prevent chill, keep room at equable temper- 
ature and let patient wear flannel or lie between blankets. 

Medication. Irritating diuretics, such as calomel, are 
dangerous in all forms of nephritis. 

Theobromine, theocine and apocynum are useless and 
may perhaps do harm in acute nephritis. 

Mild saline diuretics or alkaline mineral waters may be 
valuable, particularly in convalescence, but it may, perhaps, 
be wiser to avoid them in severe cases during the early 
stage. 

For anemia, iron may be tried, e.g., Blaud's Pill, or 
Basham's Mixture (Liquor ferri et ammonii acetatis N. F.) 
which contains iron and acts also as a mild diuretic. 

Prophylaxis. If it appears that the tonsils were the 
point of entrance or the original seat of disease their re- 
moval at a suitable time should be advised. 

Uremia. For treatment see p. 59. 



55 

CHRONIC NEPHRITIS. 

PRINCIPLES OF TREATMENT. 

1. Adequate nourishment is essential because the disease 
is chronic and a cure not to be expected. 

2. Limit demands on the kidney and guard against 
uremia by (a) diet, (&) elimination. 

3. Guard against cardiac insufficiency by avoiding physi- 
cal and mental strain. 

i 4. Avoid exposure to cold. 

METHODS. 

Methods are the same in general as for acute nephritis, 
but they must be used with regard to the condition of the 
patient and the stage and severity of the disease. 

The Early Stage, when severe, must be treated as acute 
nephritis until recognized as chronic. Nutrition then be- 
comes a more important problem. 

Exacerbations are treated like acute nephritis except that 
nutrition is more important than in acute nephritis and 
therefore diet should be more liberal. 

Latent phase; early, subacute, or chronic: 

1. Restrict the following: 

(a) Meats. (d) Alcohol. 

(b) Meat broths. (e) Acids. 

(c) Spices. 

2. To favor elimination of toxic material the following 
may be advised: 

(a) A saline cathartic every second, third, or fourth 
day. Bowels must be kept free. 

(1)) Hot tub-baths, Russian, or Turkish baths twice 
weekly. 

(c) Alkaline mineral waters with meals. 

3. Uremia. For treatment see p. 59. 

4. Cardiac Insufficiency. For treatment see hyperten- 
sion p. 25. 



57 



SYPHILITIC NEPHRITIS. 

1. Apply principles advised for acute or chronic nephritis 
according to the severity and symptoms of the case. 

2. Iodide and mercury or salvarsan should be used in 
small doses. 

3. Watch urine and omit mercury if renal irritation in- 
creases under treatment. When the diagnosis is correct 
the urine generally improves promptly. As there are no 
characteristic signs mistakes of diagnosis easily oc'cur. 

ARTERIOSCLEROTIC RENAL DEGENERATION. 
TREATMENT. 

1. Search for a cause of arteriosclerosis. If such can be 
found and if it is believed still to be operative treat it ap- 
propriately. 

Such causes are, e.g., (a) chronic lead-poisoning; (&) 
gout; (c) syphilis; (d) prolonged worry. 

2. Nutrition must be maintained. 

3. Limit the demands on the kidney by moderate restric- 
tion of: 

(a) Meats. (d) Alcohol. 

(b) Meat broths. (e) Acids. 

(c) Spices. 

4. Avoid physical and mental strain to guard against 
(a) cardiac insufficiency; (o) cerebral hemorrhage. 

5. Cardiac insufficiency, when present, should be treated 
with reference to its probable cause, e.g.: 

(a) Degenerative valve lesion, p. 25. 

(b) Degenerative myocardial lesion, p. 39. 

(c) Hypertension, p. 25. 

6. Mild toxemia may clear up under cardiac treatment if 
the heart is at fault. 

Alkaline diuretics may be of use. 

Methods advised for uremia may be used if toxemia be 
severe. 

PASSIVE CONGESTION OF THE KIDNEY. 

The treatment is that of the cause of the stasis. 



59 



UREMIA. 

Note. — ■ Uremia is an intoxication of unknown nature, 
common in severe acute nephritis and in chronic nephritis, 
and particularly so in exacerbations of the subacute stage 
of chronic nephritis. 

Symptoms vary much in degree. There may be mental 
sluggishness, drowsiness or coma, loss of appetite, nausea 
or vomiting, muscular twitchings or convulsions, head- 
ache, delirium, disturbance of vision, transient ocular 
paralysis, paresis of the extremities or paroxysmal dysp- 
noea. The urine is usually scanty or suppressed. Retinitis 
and Cheyne-Stokes respiration are common. The onset 
may be gradual, and with slight signs, or relatively acute 
and severe. Edema may be present or absent. 

Methods of Treatment. 
For mild uremia: 

1. Diet as for mild acute nephritis. 

2. Eliminative measures. 

(a) Purgation. 

(6) Sweating. 

(c) Water if there is little or no edema. 

(d) Saline diuretics. 

Severe uremia: 

1. Diet should be much restricted in quantity and quality 
as for severe acute nephritis. Vomiting or unconsciousness 
may prevent feeding for a time. 

2. Water should be used freely unless there be much 
edema. If water cannot be taken by mouth it can be used 
as salt solution by: 

(1) Hypodermoclysis. 

(2) Intravenously. 

(3) By rectum, (a) Enema. 

(o) Seepage. 

3. Purgation. Magnesium sulphate, or other purgatives 
(p. 163) may be used. Croton oil is useful especially for 
unconscious patients. If rubbed up with a little butter, 



61 



made into a ball and placed on the back of the tongue, it 
will be swallowed. Repeated doses of purgatives should 
be employed, if needed, to obtain prompt and profuse 
watery catharsis, but when there is no edema, excessive 
purgation may tend to concentrate toxins, and may thus 
do harm, unless counteracted by free administration of 
water. 

4. Sweating often does good. Hot-air baths may be used 
daily if they cause profuse sweating. They should not be 
ordered for an unconscious patient. Pilocarpine should 
not be used if there is pulmonary edema, cardiac insuf- 
ficiency or unconsciousness. 

5. Venesection. A pint or more of blood may be with- 
drawn from a vein at the elbow by incision, or, if a suit- 
able apparatus be at hand, by aspiration. 

Opinion is divided as to the need or value of injecting 
salt solution after bleeding. Ordinarily, patients do well 
without it. 

6. Colon irrigations with large quantities of hot water 
hiay be tried in the hope of promoting elimination of tox- 
ins. 

7. Drugs. The use of nitroglycerin or other vaso-dila- 
tors is followed frequently by pronounced diuresis in pa- 
tients having hypertension. The effect is transient. 

Morphine may be given subcutaneously for convulsions. 

Saline diuretics, e.g. " Cream of tartar water," * Pot. 
citrate, or " Basham's mixture," may be of use when the 
severe symptoms have subsided. 

Heart stimulants are indicated when there is cardiac in- 
sufficiency, p. 15. 



* A sat. sol. of Pot. bitartrate, the strength of which is 1 in 201, 
equal to about 40 grs. in a pint, or to 3 gm. in 500 c.c. of water, 
Lemon juice or lemon peel can be used for flavoring. 



CHAPTER III. 



ACUTE INFECTIOUS DISEASES. 



PRINCIPLES OF TREATMENT. 

Rest in bed 



fa. To conserve strength. 

]^b. To reduce metabolic waste. 



2. Ingestion of much water 



3. Bowels should be kept clear 



a. To dilute toxins. 

b. To favor their elimina- 

tion. 

a. To favor digestion. 

b. To prevent absorp- 
tion of toxic sub- 
stances. 



4. Good nursing 



fa. To secure cleanliness. 

b. To conserve strength. 

c. To promote comfort. 

d. To afford accurate information to 

physician. 

e. To facilitate treatment. 



5. Diet should be 



a. Easy to swallow. 

b. Easily digestible. 

c. Nutritious but not bulky. 

d. Palatable and varied. 



6. Meals should be 



a. Frequent and small to favor diges- 
tion. 

b. Commensurate in quantity with 
[ digestive power. 

7. The sick-room should be well ventilated. 

8. Infection of others must be prevented. 

9. Symptoms should be treated as they arise with regard 
to the circumstances of the case. 

63 



65 



TYPHOID FEVER. 

Notes. — Typhoid is characterized pathologically by pe- 
culiar ulceration of the small intestines. Ulceration is 
less lrequent in the colon and is rare in the rectum. 

Typhoid bacilli enter the blood, the organs, the secre- 
tions, and the excretions. 

The disease is self-limited, lasting from two weeks to three 
months. Relapses are common and complications frequent. 
Toxemia is often severe. 

COMMON CAUSES OF DEATH. 

1. Toxemia. 

2. Exhaustion. 

3. Severe complications. 

(a) Perforative peritonitis. 
(6) Repeated hemorrhages. 

PRINCIPLES OF TREATMENT FOR TYPHOID. 

A. Prevent infection of others. 

B. Dilute toxins and favor their elimination. 

C. Conserve strength of the patient. 

D. Diet should be suited to the individual as well as to the 
disease. 

E. Drugs are to be prescribed for definite reasons only and 
not to reduce the fever. 

F. Observe the patient's condition closely and modify treat- 
ment promptly when indicated. 

G. Have the best nursing available and if possible have a 
day-nurse and a night-nurse. 

H. Treat symptoms and complications with clue regard to 
other circumstances of the case. 

ROUTINE ORDERS TO NURSE. 

1. Enteric precautions. 

2. Dr. Shattuck's enteric diet. (Prof. F. C. Shattuck.) 

3. Baths as directed every four hours, p.r.n. 

4. Suds enema every other day or p.r.n. 

5. Spray throat and wash mouth and eyes every four 
hours. 



67 



6. Hexamethylenamine, 5 grs. (or 0.3 gm.) t.i.d. 

7. Record temperature, pulse and respiration every four 
hours, the daily excretion of urine, and the amount of food 
and water ingested. 

Specific directions for diet and baths should be given with 
due regard for the circumstances of each case. Frequent 
modification may be required. 

METHODS OF TREATMENT FOR TYPHOID. 

A. Prophylaxis. 

I. Prophylactic inoculation should be required for those 
coming into intimate contact with the patient (p. 177). 

II. " Enteric precautions." 

1. Isolation of the patient is desirable. 

2. Flies must be excluded. 

3. Those who touch the patient should wash their 

hands promptly. 

4. Eating utensils should be reserved exclusively for 

the patient and washed and kept apart. 

5. Sheets and other linen when removed from the 

sick-rocm should be soaked in 5 per cent carbolic 
acid for at least half an hour, or boiled. 

6. The best method of dealing with fasces * is that of 

Kaiser, of Groty. " It consists of adding 
enough hot water to cover the stool in the re- 
ceptacle and then adding about 14 of the entire 
bulk of quicklime (calcium oxide), covering the 
receptacle and allowing it to stand for two 
hours." 

Urine can be treated similarly by adding 
enough quicklime to bring it to a boil. 

7. Bath water may be boiled after using when practi- 

cable, but is not worth while where plumbing is 
good. 

8. Cleanliness of the attendant is essential. 



* H. Linenthal : Monthly Bui. Mass. State Board of Health, Jan. 
1914. 



69 



B. Dilution and Elimination of Toxins. 

1. The urinary output should be kept above GO oz. in 24 
hours by free administration of water. A much larger quan- 
tity of urine can be obtained but it is a question whether 
water taken in very large quantities may not favor hemor- 
rhage. Liquids, including liquid foods, should total about 
three quarts daily. 

2. The bowels should be kept clear. If they do not move 
freely suds enemata may be employed as often as necessary. 
Cathartics are to be avoided as a rule during the ulcerative 
stage because excessive peristalsis may favor hemorrhage or 
perforation. 

C. Conservation of Strength. Very important because of the 

long average duration of typhoid. 

1. The nurse should feed the patient, turn him over, al- 
low him to do nothing for himself and should make him 
comfortable. 

2. The maximum of nutrition should be maintained by fre- 
quent feedings. 

3. Visitors should be excluded entirely as a rule. 

D. Diet. 

Dr. Shattuck's principle in choosing a diet has been stated 
by him as follows: " Feed with reference to digestive power 
rather than name of disease, avoiding such articles of diet 
as might irritate ulcerated surfaces." 

Requirements: 

1. Nutritious but not bulky. 

2. Easily digestible. 

3. Non-irritating to intestine. 

4. Quantity commensurate to digestive power. 

5. Adapted to the patient's condition. 

6. Palatable and varied. 

Meals should be frequent, at least once in four hours. 
If the patient can take little at a time he should be fed 
every two hours or even every hour. 

Diet List. An enteric diet may include the following 
foods and any others that conform to the requirements 
stated above: liquid foods, strained cereals, custard, blanc- 
mange, junket, simple ice cream, soaked toast without the 



71 

crust, bread or crackers in milk, soft eggs, oysters without 
the heel, finely minced chicken, etc. 

Coleman has shown that, by the free use of milk-sugar and 
of cream, loss of weight in typhoid may sometimes be pre- 
vented. The cream can be added to milk or to other foods. 
Milk-sugar can be added to liquids, in the proportion of y 2 
oz. in 4 oz. (or 15 c.c. in 120 c.c.) of liquid. Coleman's diet, 
if used indiscriminately, may perhaps cause death. 

Departure from routine diet may be required for various 
reasons, e.g. 

1. Patient too weak to swallow solid food. 

2. Vomiting. 

3. Persistent diarrhoea, often due to milk. 

4. Severe distension, often due to milk. 

Advantages of a liberal diet. 

1. Weight and strength are better maintained. 

2. Toxemia is less. 

3. Distension is uncommon. 

4. Convalescence is shorter. 

5. Patients suffer less. 

E. Medication. Hexamethylenamine (p. 169) should be pre- 
scribed by routine as a urinary antiseptic. It may, rarely, 
cause hematuria or painful micturition. It should then be 
omitted for a few days and resumed in smaller dosage. 

Other drugs may be ordered occasionally for special symp- 
toms as required. 

Antipyretics should not be prescribed to reduce fever, but 
they may be used for headache, in the early stages of ty- 
phoid. Being depressants they are dangerous when circu- 
lation is impaired. 

F. Observation. 

I. Examine the patient once or more daily during the 
febrile stage. 
Look for: 

1. Signs of circulatory weakness. 

2. Pulmonary hypostasis. 

3. Bed sores. 

4. Changes in the condition of the abdomen. 



73 



(a) Distension of abdomen. 

(6) Spasm. 

(c) Tenderness. 

(gO Distension of bladder from retention. 

II. Keep track of: 

1. Urinary excretion. 

2. Nourishment. 

3. Account for changes in pulse or temperature. 

They may be the first sign of hemorrhage or 
perforation. 

4. Keep sterile salt-solution ready for use by hypo- 

dermoclysis or intravenously in case of need. 

III. It is the duty of the physician carefully to supervise 
treatment during the period when hemorrhage or perfora- 
tion may occur, and he himself or his assistant should be 
accessible at times when emergencies may arise. 

G. Convalescence. In the convalescence free evacuation of 
the bowels is important. 
Massage may hasten return of strength. 

H. Nursing. 

The nurse's general duties are to do her utmost to spare 
the patient exertion, discomfort and mental unrest; to re- 
port to the physician at his visit all changes in the condi- 
tion of the patient; to be prepared to answer questions as 
to the effect of treatment prescribed; and to notify the phy- 
sician at once of alarming symptoms or signs suggesting 
severe hemorrhage or perforation. She should know the 
possible significance of sudden changes in pulse rate and 
temperature and should look for blood in every fcecal de- 
jection. To prevent accident she should, as far as possible, 
avoid leaving the patient alone even when he is not ap- 
parently delirious. 

The following complications can generally be prevented 
by an experienced nurse: — 

1. Bed sores. 5. Boils. 

2. Corneal ulceration. 6. Cracked lips. 

3. Middle-ear infection. 7. Tender toes. 

4. Parotitis. 8. Hypostatic congestion. 



1. To prevent bed sores: — 

(a) Keep sheets smooth, clean and dry. 

(b) After soiling, clean the skin promptly, dry it, rub 

in zinc oxide ointment, and powder with 
starch. 

(c) Change the patient's position occasionally. 

(cl) Do not allow prolonged pressure on bony promi- 
nences. 

(e) If a red spot appears where there has been pres- 
sure keep pressure off that part by rings or 
pads and paint the spot with picric acid, 1%. 

2. To prevent corneal ulceration keep cornea clean by 
bathing the eyes every four hours with a 2% watery solu- 
tion of boric acid. 

3. Boils in crops are generally due to the use of dirty 
sponges. If a boil appears care must be taken to avoid 
spreading the infection. 

4. Cracked lips can be prevented by the use of cold cream. 

5. Middle-ear infection or parotitis may result from im- 
proper care of the mouth. The mouth should be cleaned 
and the throat sprayed every four hours with a non-irri- 
tating antiseptic. Dobell's solution, or " alkaline antisep- 
tic " will serve, diluted, if necessary, with one or two parts 
cf water to avoid irritation of the mucous membranes. Ex- 
cessive dryness of the tongue from mouth breathing can be 
prevented by the use of vaseline. 

6. Hypostatic congestion of the bases of the lungs is due 
in part to protracted lying in one position. It can be com- 
bated, if not prevented, by rolling the patient on one side 
and supporting him in this position for an hour or more by 
means of a pillow. The patient should then be rolled onto 
the other side for another period of time, and these man- 
oeuvres should be practiced at least once daily. 

SYMPTOMATIC TREATMENT FOR TYPHOID. 
Fever and Toxemia. 

Hydrotherapy generally acts well. 
Benefits expected from it are: 

1. Fall of temperature of from 1 to 2 degrees. 



Vi 



2. Fall in rate with increase of force and volume of the 
pulse. 

3. Deeper breathing and diminution of pulmonary hypo- 
stasis. 

4. Better sleep. 

5. Diminution of symptoms of toxemia. 

Routine bath order. For temperature * of 103.5° rectal 
give bath every four hours at 85°. For every half degree 
of temperature above 103.5° lower temperature of bath- 
water 5°. 

Rules for use of baths: 

1. Baths should be ordered for definite indications only. 

2. For children and for thin and feeble patients, baths 
should be warmer and shorter than for the robust adult. 

3. The physician should supervise the first bath and pre- 
scribe subsequent baths with regard to the effect of the first 
one. 

4. If the pulse gets weaker the bath should be stopped. 

5. Much cyanosis or shivering after the bath indicates that 
it was too cold, or too long, or that not enough friction was 
used. 

6. Stimulants are seldom required before or after a bath 
that is suited to the case and well given. 

7. Baths must be modified or omitted if they greatly excite 
the patient, interfere with sleep, or cause a rise of tempera- 
ture. 

Methods of bathing: 

"• M. G. H. Typhoid Bath." With rubber sheet, supported 
at edges by rolls of blanket make tub in bed of patient. 
Dash water over him, and rub vigorously in turn, with the 
hands, the chest, limbs, and back, but not the abdomen. The 
duration of the bath should be 20 minutes or less if so or- 
dered. 

Sponge baths often act well and are preferred in many 
cases. 



* Temperatures in typhoid are best taken by rectum because these 
are more reliable than mouth temperatures. The rectal temperature 
averages about 1° higher than the mouth temperature. 



79 



acid solution in water at the required temperature can be 
used for bathing. 

CIRCULATORY WEAKNESS.* 

I. Cardiac weakness may be caused by various conditions 
which are difficult to distinguish from one another, e.g., 

1. Exhaustion or lack of nourishment. 

2. Preexisting cardiac lesions. 

3. Deranged nervous control. 

4. Cloudy swelling. 

5. Fresh endo-, myo- or pericarditis. 

Symptoms generally develop gradually so that there is 
plenty of time to prescribe. 

Stimulants may be ordered if the pulse becomes weak or 
irregular or goes above 120. They may act well or not at 
all, and their use must often be tentative. 

Digitalis, strychnine, caffeine or other drugs may be tried. 

Emaciated or septic patients taking little food may do well 
on alcohol. It seems sometimes to act as a food, and in- 
directly as a stimulant. 

II. Vasomotor paresis (p. 33) is suggested when the pulse 
is weak in proportion to the heart sounds. The condition 
can generally be recognized if its mode of development has 
been noticed. 

The best remedy is a saline infusion. It may cause a 
rapid fall in the pulse rate and a marked improvement in 
the pulse. It may be necessary to repeat the infusion after 
some hours or it may not be required again. 

DIARRHCEA. 

Severe diarrhoeas are dangerous and must be checked. 

1. Examine stools to determine if they contain undigested 
food. If so, omit that kind of food or reduce the amount. 
Curds from milk may be found. 

2. Tincture of opium or Paregoric generally acts well. 

CONSTIPATION. 

Constipation is a frequent cause of fever in convales- 
cence. Calomel or Fl. Ex. of Cascara Sagrada, Castor-oil 



Chap. I, p. 31, 3; 



81 



or "Russian oil" (p. 179) may be given at this stage. 
Foecal impaction should be avoided. 

DISTENSION. 

1. If stools show curds reduce or omit milk. 

2. Turpentine stupes * may give relief and can be used 
p.r.n. 

3. Rectal tube may be tried. 

VOMITING. 

Reduction or modification of diet is advisable for a time 
at least. Swallowing small pieces of cracked ice, or a tea- 
spoonful of shaved ice with brandy may relieve. 

HEADACHE. 

If not relieved by an ice-cap placed on the forehead, phe- 
nacetin fr. 5 to 10 grs. (or 0.3 to 0.6 gm.), with caffeine 
citrate 1 gr. (or 0.065 gm.), or some other analgesic may 
be prescribed. 

COMPLICATIONS. 

I. HEMORRHAGE FROM THE BOWEL. 

Signs. First sign of small hemorrhage is blood in the 
stool. First sign of large hemorrhage may be a rapid fall 
in temperature and a rise in the pulse rate. 

Treatment. 1. Omit nourishment, water, and baths. 

2. Give nothing but cracked ice by mouth for 24°. 

3. Give morphine subcutaneously — repeat dose in 15 
minutes or half an hour and repeat again at half-hour in- 
tervals until the respiration becomes slower. Do not let 
the respiration fall below 10 per minute. When it has 
reached 15 or less give morphine in small dosage, if at all, 
lest poisoning result. 

The object of using morphine is to stop peristalsis and to 
keep the patient quiet until the hemorrhage has ceased. 

4. If the patient be exsanguinated raise the foot of the 



* See textbook on nursing. 



83 



bed to prevent death from syncope but do not stimulate un- 
less there is imminent danger, because increase of blood- 
pressure may prolong the hemorrhage. 

The best circulatory stimulants for this condition are a 
saline infusion or a direct transfusion of blood. 

5. For small hemorrhages narcotization with morphine 
may not be required. 

6. Patients who are very weak or emaciated should be fed 
in spite of hemorrhage. 

II. PERFORATION. 
Treatment. — Surgical. Early diagnosis and prompt oper- 
ation are essential to success. When the condition of the 
abdomen has been watched closely before the appearance 
of the symptoms of perforation the diagnosis will be easier. 
Spontaneous recovery is extremely rare. 



RHEUMATIC FEVER. 

Note. — The disease, when typical, is characterized by a 
migratory articular and peri-articular inflammation with 
pyrexia and leucocytosis. When untreated the inflammation 
generally lasts about six weeks. Relapses are common and 
endocarditis is frequent. Pericarditis or myocarditis is seen 
occasionally. 

There is reason to believe that rheumatic fever is a form 
of infectious arthritis. Perhaps most of the cases are due 
to a specific organism. 

PRINCIPLES OF TREATMENT. 

1. Rest in bed. 

2. Relieve pain. 

3. Dilute and eliminate toxins. 

4. Prescribe large quantities of salicylate and of alkali. 

5. Prevent recurrence. 

6. Watch for cardiac complications. 

METHODS. 
1. Relieve pain by protecting the joints with cotton and 
bandages or by splints. Oil of gaultheria may be rubbed on 



85 

the skin before bandaging and fomentations may be useful. 
Occasionally, when pain permits, a hot bath gives much 
relief. If the pain be severe and not controlled by other 
means use morphine hypodermic-ally until the salicylate has 
had time to act. 

2. Dilution and elimination of toxins can be promoted by 
the free administration of water. Three quarts or more 
should be ingested in twenty-four hours unless the heart 
be weak. Cardiac complications may require limitation 
of liquids. 

The bowels should be kept clear. Cathartics may be pre- 
scribed as needed. 

3. Food should be nutritious and as abundant as can be 
digested because wasting is often rapid and anemia may de- 
velop. 

4. Medication. Sodium salicylate (p. 1G7) or some other 
salicyl compound should be prescribed in large dosage. The 
quantity should be proportional to the degree of pain and 
acuteness of the inflammation. For severe cases 10 grs. 
(or 0.G5 gm.) may be ordered every hour until the patient 
is relieved or toxic. To avoid irritation of the stomach 
every dose should be given with a full glass of water. 
Large doses of sodium bicarbonate seem to diminish the 
toxic, effects of salicylates. Twenty grains or more of soda 
may be ordered with every dose of salicylate. Enough soda 
should be taken to render the urine alkaline. 

Salicin is a good substitute for sodium salicylate and 
seems to cause less gastric disturbance. Aspirin,* or Oil of 
wintergreen, may be tried. 

"When symptoms have been relieved the dose of the drug 
can be reduced. It should be continued for a month or 
more after the patient is apparently well. 

When salicylates act well, in from twenty-four to forty- 
eight hours, a fall of temperature occurs, and with it there 
comes diminution of joint swelling and marked relief from 
pain. 

The common symptoms of salicylate poisoning are nausea 
cr vomiting, tinnitus, headache and occasionally erythema 



* Incompatible with alkalis. (N.N.R.) 



87 

or delirium. When these occur the drug must be omitted 
until they subside. It may then be resumed in smaller 
dosage or in different form. 

5. Recurrence of arthritis is common early or late. 
Early recurrence can generally be avoided by keeping the 

patient in bed for a week after the inflammation has en- 
tirely subsided and by continuing the use of sodium sali- 
cylate, fr. 30 to 40 grs. (or 2 to 3 gm.) daily, for one month 
or more after convalescence. Exercise should be resumed 
gradually. 

Late recurrence and future cardiac disease can often be 
prevented by eliminating all foci of suppuration. Inflam- 
mation of the tonsils or genital tract, sinus infection and 
pyorrhoea alveolaris should be looked for. Tonsillectomy 
may reveal deep suppuration not demonstrable externally. 
Tonsillectomy * should be insisted on if the tonsils are a 
likely source for future infection. Pyorrhoea can be bene- 
fited by rubbing the gums daily with a solution of potas- 
sium permanganate and by rinsing or sponging the mouth 
frequently with hydrogen peroxide (p. 149). 

6. Cardiac complications may be latent or severe. Cir- 
culatory weakness may require limitation of liquids. 

The patient should remain flat in bed for weeks or 
months after the disappearance of all signs of active cardiac 
infection, and should avoid exertion of all kinds for several 
months thereafter to give the heart ample time to hyper- 
trophy or to adjust itself to the changes. 

There is reason to believe that salicylates taken in large 
quantity tend to ward off endocarditis. 

For further information on endocarditis see Chapter I, 
page 21. 

LOBAR PNEUMONIA. 

Notes. — An acute infectious disease of multiple etiology, 
most commonly caused by the pneumococcus. The rate of 
the pulse and respiration are indices of toxemia. 



* Dangerous while the tonsils are acutely inflamed. 



so 



Mortality commonly due to: 

1. Toxemia r («) Cardiac dilatation. 

'}{!)) Vasomotor paresis, 
less often to f (a) Empyema. 

2. Complications. J (b) Pericarditis. 

I (c) Endocarditis. 

PRINCIPLES OF TREATMENT. 

1. Secure good nursing and fresh air. 

2. Eliminate and dilute toxins. 

3. "VVatch circulation. 

4. Stimulate promptly when required. 

5. Prescribe drugs only for definite reasons. 

6. Take precaution to prevent accident. 

7. Diet suitable to case. 

8. Recognize complications promptly. 

METHODS. 

1. Eliminate toxins by requiring copious ingestion of 
water, unless the heart be weak, and keep the bowels clear. 
Watch urinary output to see that the water is being ex- 
creted. 

2. Out-of-door treatment is likely to benefit robust pa- 
tients, but the old and feeble are likely to do better indoors. 
Fresh air is, perhaps, the best stimulant in pneumonia. 
Sometimes it diminishes dyspnoea and promotes comfort. 

3. Note the outlines and sounds of the heart and the qual- 
ity of the pulse at every visit. 

4. Stimulation is indicated (a) if the quality of the pulse 
be poor, (fr) if it becomes irregular or (c) if the rate go 
above 120. 

Irregularity early in the illness is less apt to herald 
danger than that developing late. 

5. Morphine is indicated to relieve pleuritic pain when a 
tight swathe fails to do so. Sleep is very important to 
conserve the strength of the patient and morphine may 
be used to obtain it, especially in the early stages of pneu- 
monia. 

Morphine is contraindicated whenever bronchial secre- 



91 

tion is profuse, because it checks expectoration, and if mor- 
phine is to be used in the later stages caution is necessary. 

6. Diet should consist of food that requires no chewing 
and that is easily swallowed; i.e., liquids and soft solids. 

The amount should be gauged by the digestive power of 
the individual, but the course of the disease is so short 
the nutrition is seldom important. 

7. Avoid renal irritants and gas-producing foods. 
Besides the complications above-mentioned look out for 

a true nephritis. 

8. When temperature is very high and the heart doing 
well, sponge baths may be used to reduce the fever. 

9. Tympanites may require treatment. An enema of 1 
oz. (or 30 c.c.) of glycerine undiluted generally acts well. 

10. Dyspnoea with cyanosis can be relieved to some ex- 
tent by inhalation of oxygen passed through absolute alco- 
hol. 

STIMULATION OF HEART. 

On the third or fourth day, 10 m. (or 0.6 c.c.) of Tr. 
digitalis may be ordered t.i.cl. It may, perhaps, ward off 
sudden dilatation of the heart. 

For irregularity or weakness caffeine sodio-salicylate may 
be used subcutaneously, and at the same time digitalis can 
be given by mouth for subsequent effect, or digipuratum 
solution (p. 159) can be injected instead of caffeine. 

For acute cardiac dilatation the following remedies may 
be tried according to circumstances: 

Subcutaneously: 

1. Digipuratum-solution. 

2. Camphor in oil: 3 grs. (or 0.2 gm.). It should be 

specially prepared for subcut. use. 

3. Caffeine sodio-salicylate: 3 grs. (or 0.2 gm.). It may 

cause irritability or wakefulness. 

4. Alcohol or ether: 1 drach. (or 4 c.c). 
Intravenously Digipuratum-solution or Strophanthin (p. 

159) may be given. The latter is dangerous. 
By mouth: 

1. Brandy, fr. i to 1 oz. (or 15 to 30 c.c). 

2. Aromatic spirits of ammonia, 1 drach. (or 4 c.c). 



93 

Venesection may do good if there is cyanosis with much 
engorgement of the right ventricle. 

Acute pulmonary edema yields occasionally to a large 
dose of atropine y 60 gr. (or 0.001 gm.) given subcutane- 
ously. 

Vasomotor paresis. The momentary application of cold 
in the form of an ice-bag to the abdomen may do good by 
causing reflex vascular contraction. Salt solution subpec- 
torally or intravenously may be beneficial. If improvement 
results follow it up with caffeine. 

DELIRIUM: TREATMENT. 

Active delirium may be ameliorated by morphine (see 
sect. 5, p. 89), by hypnotics, or sometimes by hyoscine hydro- 
bromate * used subcut. Alcohol internally may be of serv- 
ice for delirium with exhaustion. 

Delirium, even when slight may be dangerous. When 
the nurse leaves the room even for a moment some one 
should take her place lest the patient jump from the win- 
dow. No razor or weapon of any kind should be left about. 

BRONCHO-PNEUMONIA. 

Treatment is essentially the same as for lobar pneumonia 
except that the disease generally runs a milder, but longer 
course. Nutrition, therefore, is more important. 

Bronchitis is often associated with broncho-pneumonia 
and, when this is the case, expectorants may be of service 
during convalescence. 

ACUTE INFLAMMATION OF THE UPPER 
RESPIRATORY TRACT. 

Etiology: infectious in most instances. The pneumococ- 
cus, staphylococcus, influenza bacillus, diphtheria bacillus, 
micrococcus catarrhalis or other bacteria may be causative. 
Among predisposing factors lowered physical resistance and 
exposure to cold are important. 



* Scopolamine is chemically the same as hyoscine. (U.S.D.) 



95 



Course of Disease. Inflammation generally begins in the 
nasopharynx (pharyngitis). It usually extends within a 
few days to the nasal mucous membrane (coryza) and often 
to the tonsils (tonsillitis) or larynx (laryngitis). The se- 
verity and extent of the inflammation depends chiefly on 
the kind and virulence of the infecting organism and on 
the resistance of the patient. 

Complications and Sequelae. 

1. Bronchitis. 8. Bronchiectasis. 

2. Otitis media. 9. Septicaemia. 

3. Peritonsillar abscess. 10. Meningitis. 

4. Lobar or broncho- 11. Peritonitis. 

pneumonia. 12. Inflammation of the 

5. Arthritis. antrum, frontal, 

6. Endocarditis. ethmoidal or sphe- 

7. Glomerulo-nephritis. noidal sinuses. 

Diagnosis. Exclude whooping-cough, scarlet fever, meas- 
les and diphtheria. The diagnosis of diphtheria, in some 
cases, can be made by culture only. Therefore the safest 
plan is to take a culture in every case of inflammation of 
the throat and to repeat it, if the report be negative but 
the signs suggestive of diphtheria. 

PROPHYLAXIS. 

1. If there is a reasonable probability that the symptoms 
are due to diphtheria or to one of exanthemata isolate the 
patient provisionally. 

2. If the clinical evidence points to diphtheria adminis- 
ter antitoxin (p. 151) to the patient without waiting for the 
culture; or even if the first culture be negative. 

Prophylactic inoculation of all persons exposed to diph- 
theria should be insisted on. 

3. Patients having infections of the respiratory tracts 
should cover the mouth on coughing or sneezing. 

4. Good ventilation of rooms occupied by the patient re- 
duces risk of contagion. 

TREATMENT APPLICABLE IN GENERAL. 

1. Keep the patient in a warm, but well-ventilated room 
at a uniform temperature, 



97 



2. Promote rest and sleep, using sedatives or hypnotics 
when needed. 

3. Move bowels, at cutset, by enema or cathartic unless 
they have been acting freely. 

4. Allay unproductive or irritating cough. 

5. Avoid local irritation by tobacco or concentrated 
liquor. 

6. Cleanse mucous membrane frequently, and soothe in- 
flammation by means of a non-irritating gargle. Warm 
water, with or without salt or sodium bicarbonate in it, or 
Liquor antisepticus alkalinus may be used diluted with 
3 parts of warm water. 

7. Antipyretics, e.g., phenacetin fr. 5 to 10 grs. (or 0.3 
to 0.G5 gm.), with caffeine citrate 1 gr. (or 0.065 gm.), or 
salicyl preparations (p. 167), may alleviate discomfort espe- 
cially if there be fever, malaise or pain. 

S. Food should be readily digestible and easy to swallow. 

Abortive Treatment. This can be effective in the early 
stages only, and seldom even then. The following meas- 
ures may be tried. 

1. Cleansing, ncn-irritating gargle. 

2. Hot bath before retiring, or 

3. Hot drink on retiring to produce sweating. 

4. Early to bed, and hypnotic unless sleep comes quickly. 

5. Catharsis by calomel or saline. 

6. The patient should dress in a warm room and avoid 
cold bathing on the following morning. 

METHODS OF TREATMENT. 

ACUTE PHARYNGITIS. 

1. Cleansing gargle every four hours. 

2. Oil spray * after gargle to protect and soothe mucous 
membrane. 

3. Check cough with lozenges or sedatives. 



* Petrolatum liquidum will serve. Menthol 5 grs. (or 0.3 gm.) or 
Eucalyptol 5 min. (or 0.3 c.c.) or both can be added per oz. (or 30 
c.c.) of liquid petrolatum. The De Vilbiss atomizer is good. 



99 



CORYZA. 

Keep the nose as free as possible from secretion. 

Irrigation of the nose with an alkaline solution often 
gives much relief, but some physicians believe that this 
practice may lead to inflammation of the frontal sinus or 
middle ear. An oil spray (p. 97) may be used to free the 
nasal passages. 

If the secretion be profuse and watery, its quantity can 
be diminished by using ^o & r - (° r 0.00032 gm.) of atro- 
pine sulphate and repeating it in fr. 4 to 6 hours s.o.s. 
Atropine is contraindicated when secretion is viscid or te- 
nacious. Excessive dosage causes dryness of the throat, 
increases discomfort, and may cause severe poisoning. 

Atropine can be used in the form of Tr. of belladonna 
leaves; dose from 10 to 30 min. (or 0.6 to 2 c.c). 

ACUTE TONSILLITIS. 

1. Take a culture. 

2. Whereas the constitutional symptoms are apt to be 
severe it is generally advisable to keep the patient in bed. 

3. Prescribe cleansing gargle to be used every four hours. 
The tonsils may be painted daily with argyrol,* fr. 10 to 
20% in watery solution. 

4. An oil-spray (p. 97), used after gargling, may give 
some relief. 

5. An ice-bag collar may help much to relieve pain in the 
throat. 

6. The diet must be easy to swallow. Cold drinks may 
be grateful. 

7. Occasional doses of phenacetin or of salicylate (p. 
167) may be beneficial for fever, malaise or pain. 

8. Opiates or hypnotics are indicated sometimes. 

9. Salicylate (p. 167) in large doses acts well in some 
cases of tonsillitis having slight articular symptoms due 
probably to streptococcus infection. 

10. Note at first visit the size, position and sounds of the 
heart, and the presence or absence of murmurs. Watch 

* u. s. t. 



101 



for any change and before discharging the patient, deter- 
mine whether the heart or the kidneys have suffered. 

ACUTE LARYNGITIS. 

1. Scarification, intubation or even tracheotomy may be 
required for edema. 

2. Steam, plain or medicated, ordinarily gives relief. It 
should be used every few hours or as desired. The steam 
can be inhaled from the mouth or from a pitcher contain- 
ing boiling water. To the water may be added 1 drach. 
(or 4 c.c.) of compound tincture of benzoin. A steam 
atomizer is better still. The " Acme " is good, and it can 
be used to spray oil and steam together. For very sensi- 
tive throats the steam and oil may act better without other 
ingredients, but Menthol 5 grs. (or 0.3 gm.), or Eucalyptol 
5 min. (or 0.3 c.c), or both can be added per oz. (or 30 
c.c.) of Liquid petrolatum. 

Excessive dryness of the air of the room is harmful. 
It can be mitigated by allowing steam to escape constantly 
from a kettle or chafing dish. 

3. Cough must be checked and talking minimized. 

4. Smoking is especially harmful as a rule. 

ACUTE TRACHEITIS. 

Treatment as for laryngitis may suffice. 

A flaxseed or mustard poultice * for the upper chest or 
steam inhalation may help to relieve substernal distress. 
Mustard should be avoided if resulting pigmentation would 
contraindicate its use. " Gomenol jujubes " f taken every 
3 to 6 hours may relieve. 

BRONCHITIS. 

ETIOLOGY. 

Acute bronchitis commonly follows infections of the 
upper respiratory tract and especially infections by the 



* See textbook on nursing. 

f A preparation of oleum cajuputi (U.S.), 



103 



pneumococcus or influenza bacillus. It occurs sympto- 
matically in some infectious diseases, e.g., typhoid and 
measles. 

Chronic bronchitis is often associated, in old or middle- 
aged persons, with slight cardiac insufficiency or with 
emphysema. Rarely, gout is a factor. 

DIAGNOSIS. 

Acute or chronic bronchitis may be simulated by tuber- 
culosis and, therefore, sputum examination is imperative. 
Many cases of bronchiectasis following influenza are 
wrongly diagnosed as bronchitis or as phthisis. 

ACUTE BRONCHITIS: TREATMENT. 

1. The patient should keep warm and avoid change of 
temperature by staying indoors. 

2. If there is fever, bed may be advisable or necessary. 

3. Bronchial secretion must be expectorated, but unpro- 
ductive cough should not be allowed to fatigue the patient 
or to prevent sleep. 

If the cough comes from pharyngeal irritation, lozenges 
may suffice to check it; if from the larynx or trachea, 
steam inhalations (p. 101) may be serviceable. If neces- 
sary for relief of cough codeine sulphate \ gr. (or 0.01G 
gm.) or heroine hydrochloride* T \ gr. (or 0.005 gra.) may 
be prescribed for use in the afternoon or at night. Morn- 
ing cough is generally needed to clear the lungs. It can 
be promoted by a hot drink. 

4. Substernal distress or pain, see tracheitis, p. 101. 

5. Expectorants are contraindicated during the acute 
stage of bronchitis because they irritate the inflamed mu- 
cous membrane. They may be used during convalescence, 
at which time the expectoration is often tenacious and diffi- 
cult to raise. 

6. Several weeks are generally required for complete re- 
covery, but when the patient feels well he may be allowed 



* The hydrochloride of the diacetic ester of morphine (U.S.D.) not 
trial. "Heroin" is a name bearing U.S. and (N.N.R.). 



105 



to resume his occupation. Smoking and cold bathing 
should be resumed cautiously and unnecessary exposure 
should be avoided as long as expectoration persists. 

CHRONIC BRONCHITIS: TREATMENT. 

1. Expectorants are generally beneficial, particularly po- 
tassium iodide in the dose of fr. 5 to 10 grs. (or 0.3 to 
0.6 gm.), t.i.cl. 

2. When there is any sign of cardiac insufficiency, ap- 
propriate stimulants are indicated. For slight insufficiency 
the Compound Squill Pill may act well both as a heart 
stimulant and as an expectorant. The usual dose is from 
6 to 9 pills daily. They should be freshly prepared. Syste- 
matic cardiac treatment may be required. 

3. An equable and warm climate may promote comfort, 
especially for elderly persons. 

4. If the presence of bronchiectasis be suspected treat 
the case as one of bronchiectasis (p. 107). 

5. Acute exacerbations of chronic bronchitis may be 
treated much as is acute bronchitis, but severe symptoms 
generally indicate that some form of pneumonia has de- 
veloped, and treatment should be regulated accordingly 
(p. 89). 

6. Codeine sulphate or heroine hydrochloride should not 
be used consecutively over long periods on account of the 
danger of forming a habit. 

7. The bronchitis of overfed patients is often benefited 
by depletion. Exclude gout as a factor. 

Note. — Much improvement may be hoped for but cure is 
hardly to be expected in chronic bronchitis. 

BRONCHIECTASIS. 

Note. — The disease is chronic, lasting for thirty years, 
more or less. The patient may* be subject to recurring at- 
tacks of broncho-pneumonia, or of hemoptysis. Many pa- 
tients have emphysema or asthma.* The condition is often 



* Empyema, abscess, arthralgia, or pneumothorax occur in rare ii 
stances. 



107 



diagnosed wrongly as bronchitis or tuberculosis. Many 
cases are traceable to influenza. The sputum, typically, is 
abundant, purulent, greenish, nummular, can be raised at 
will by coughing, and often contains abundant influenza 
bacilli as well as various other organisms. Repeated ex- 
aminations may be necessary to demonstrate the influenza 
bacilli. The cavities may be localized in one lobe or dis- 
seminated throughout both lungs. Nutrition is generally 
good. As the physical examination may show only a few 
rales, the diagnosis must rest on the history, the character, 
and the amount of the sputum. 

TREATMENT. 

No method yet devised offers hope of cure. 
Efforts must be directed to relieving the patient as far 
as possible from unpleasant symptoms. 

1. Teach the patient to drain his cavities on rising in the 
morning, and, if necessary, once or twice later in the day. 
This can be facilitated by taking a drink of hot water, tea 
or coffee at such times. Potassium iodide fr. 5 to 10 grs. 
(or 0.3 to 0.65 gm.) or other expectorants may be used if 
the secretion be too viscid to come up readily. 

2. Avoid sedatives because they check free expectora- 
tion. The material then decomposes in the cavities and 
gives a foul odor to the breath and to the sputum. 

3. In extreme instances of retained secretion the condi- 
tion with its dyspnoea and cyanosis may simulate bronchial 
asthma. A differential diagnosis can be made from history 
and sputum. An emetic will give immediate relief by 
clearing the lungs. 

4. Most of these patients are better in warm weather. A 
uniformly mild climate may relieve but cannot cure. 

5. Sputum must not be swallowed because diarrhoea may 
result. 

6. Foul-smelling sputum means inefficient drainage of 
cavities. The odor can be ameliorated by the use of 3 min. 
(or 0.2 c.c.) of Eucalyptol on a lump of sugar several times 
daily. 

7. When the disease is localized in one lobe of the lung 
the chance of relief by surgical means may be considered. 



CHAPTER IV. 



GASTRIC AND DUODENAL ULCER. 

INDICATIONS FOR MEDICAL TREATMENT. 

1. Recent ulcers. 

2. Chronic ulcers with mild symptoms. 

3. Chronic ulcers which have not had satisfactory med- 
ical treatment. 

4. Ulcers for which surgical treatment is too dangerous 
or has been refused. 

5. As a preparation for operation. 

The prognosis under medical treatment is better the 
more recent the ulcer. 

PRINCIPLES OF TREATMENT. 

The principles and methods are essentially the same 
whether the ulcer is in the stomach or in the duodenum. 

1. Prolonged rest for the patient and for the digestive 
tract. 

2. Avoidance of food mechanically or chemically irri- 
tating. 

3. Reduction of gastric secretion to the minimum. 

4. Good care of teeth. 

METHODS. 

A. Rest in bed for a month is essential. 

B. Diet should consist chiefly of soft carbohydrates, 
fats, milk, and eggs. Feeding should be frequent. 

Treatment may be begun by starvation for several days, 
with or without nutritive enemata. If the patient be 
strong and if he absorbs nutritives well they may be used 
during the first week without any mouth feeding. During 

109 



Ill 



the period of starvation three pints of salt solution should 
be given daily by rectum. Cracked ice may be sucked to 
allay thirst. 

Begin feeding with small quantities of milk (see Vomit- 
ing, p. 121). Later, bread, or crackers and milk, milk toast, 
strained cereals with cream and sugar, rice, custard, blanc- 
mange, junket, simple ice cream, mashed or baked potato 
with cream or butter, eggnog, raw or soft boiled or dropped 
egg, purees, soft fruits, etc., can be added later to the 
dietary until the patient is taking ample nourishment. 

The nutritive value of liquids can be much increased 
by adding to them sugar of milk, fr. i to 1 oz. in 4 oz. (or 
fr. 15 to 30 gm. in 120 c.c.) of liquid. Cream may be added 
to milk, and butter should be used freely. 

Irritating foods, e.g., coarse vegetables, condiments, acids, 
and particularly alcohol must be avoided. 

Hot drinks and meat broths, as a rule, should not be 
taken. 

Proteid foods, in the opinion of the writer, are to be 
avoided, as a rule, except in the form of milk or eggs. 

G. Modification of diet is required for patients that are 
emaciated, or feeble and anemic. For them starvation may 
be harmful, and it may be wise to begin feeding by mouth 
soon after the hemorrhage has stopped, and quickly to in- 
crease the amount of food ingested in order to accelerate 
healing by improved nutrition. The experience of the pa- 
tient requires consideration. 

In marked contrast to those expressed above are the 
views held by some physicians who advocate a diet con- 
sisting chiefly of proteid. Their aim is to neutralize the 
acid as fast as it is formed by means of proteid. Frequent, 
feedings are recommended with the same object. 

Lenhartz is one of these, and his method may be pre- 
ferred for some cases. His diet schedule follows, p. 117. 

D. Reduction of gastric secretion * may be favored by 
starvation, by a diet low in proteid, by the avoidance of 
salt and by the administration of a tablespoonful of olive 
oil several times daily. 



* Small doses of atropine are recommended by some physicians, 



113 



E. Medication: 

1. Sodium bicarbonate should be prescribed freely for 
relief of pain or distress in the dose of fr. \ to 1 teaspoon- 
ful, or more if required, in a glass of water. A hot water 
bag may relieve. 

2. After feeding has been begun bismuth subnitrate 
should be given three times daily in teaspoonful doses 
before meals with the hope of benefit by coating the ulcer 
mechanically. Bismuth is not constipating in this dose. 
It is important that the drug should be pure.* 

3. The bowels should be kept free by enema or by mild 
cathartics. Milk of magnesia acts well as a cathartic and 
is also an antacid. 

D. Convalescence: 

1. General hygienic measures including attention to the 
bowels are important. 

2. Work should be resumed gradually and much fatigue, 
psychical more than physical, should be avoided. 

3. Rest, lying down, for from \ to 1 hour after meals is 
of great benefit. 

4. Food should be taken in the middle of the morning, 
the middle of the afternoon and at bedtime in addition to 
regular meals. 

5. The more strictly the diet and regimen can be followed 
the greater the chance of success but it is better to en- 
large the dietary than to undernourish the patient because 
good nutrition favors healing of the ulcer. The treatment 
should be followed as strictly as practicable for from six 
months to a year. 

COMPLICATIONS: TREATMENT. 

A. Hemorrhages, when small, require no special treat- 
ment. 

When a severe hemorrhage occurs the patient should lie 
as still as possible and morphine should be given subcu- 
taneously in dosage sufficient to bring the patient well 
under its influence and to inhibit peristalsis (p. 81). Fur- 
ther medication i« not likely to do good. 



Squibb' s is good for this purpose. 



115 



An ice-bag may be placed over the stomach. 

Stimulation of the circulation by salt solution, by trans- 
fusion of blood, or by drugs should be withheld unless de- 
manded by immediate danger, because raising the blood- 
pressure may prolong the hemorrhage. 

If syncope be feared after hemorrhage it may be advis- 
able to raise the foot of the bed. 

Operation is seldom indicated during hemorrhage be- 
cause most hemorrhages stop spontaneously, and because 
when the patient has become exsanguinated operation is 
dangerous. 

Repeated hemorrhage is an indication for operation after 
the patient has recovered sufficiently from the resulting 
anemia. Transfusion may be advised to hasten recovery 
or to prepare for subsequent operation. 

B. Perforation may be acute or subacute. It may lead 
to general peritonitis, to abscess, or to adhesions causing 
persistent, severe symptoms. 

The acute perforations and those with abscess formation 
should receive prompt surgical treatment. Early diagnosis 
is very important. 

C. Pyloric obstruction, when severe, requires operation. 
Incomplete obstruction with gastric dilatation can often 
be relieved temporarily and sometimes for long periods by 
rest in bed, lavage daily before breakfast, and a soft diet 
with limited liquids. Under such treatment the dilated 
stomach may contract and acute inflammation at the py- 
lorus may subside. 

This is an excellent preparation for operation. Opera- 
tion should be urged early for pyloric obstruction because 
when the symptoms have become imperative the weakened 
condition of the patient adds greatly to the risk. 

D. Persistent severe symptoms which do not yield to 
medical treatment demand that operation be seriously con- 
sidered. 



117 



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119 



ACUTE GASTRITIS AND GASTRO- 
ENTERITIS. 
Pathology: Acute irritation, probably with hyperemia, 
and possibly with inflammation of the mucous membrane 
of the stomach, of the intestines or of both. 

Etiology: 1. Ingestion of food unwholesome either in it- 
self or for the individual. 

2. Excess of food. 

3. Excess of alcohol or other beverage. 

Diagnosis of gastritis with vomiting is made by history 
and by exclusion. 

Do not overlook the following diseases which may cause 
vomiting: 

1. Acute infectious dis- 7. Acute drug poisoning. 

eases including ma- 8. Brain tumor, 

laria. 9. Tabes dorsalis. 

2. Nephritis. 10. Angina pectoris. 

3. Pregnancy. 11. Chronic gastric or in- 

4. Migraine. testinal diseases. 

5. Lead colic. 12. Acute surgical condi- 

6. Hysteria. tions, e.g., appendici- 

tis, cholecystitis, re- 
nal colic, etc. 

PRINCIPLES OF TREATMENT. 

1. Rest and warmth for patient. 

2. Removal of cause of symptoms. 

3. Rest for digestive tract. 

4. Symptomatic treatment. 

METHODS. 

Methods must be chosen with regard to the cause, se- 
verity and nature of symptoms. 

1. Rest and Warmth. The patient should lie down and 
should be warmly covered or should remain in bed. Hot- 
water bags may be useful for cold extremities or for ab- 
dominal distress or pain. Rest and warmth diminish 
metabolic waste and promote recuperation. 

2. Removal of Cause. If the distress is gastric, and if 



121 



the stomach has not been freely emptied, emesis may be 
induced by administering quantities of warm water or by 
means of a teaspoonful of mustard-powder mixed in a cup 
of warm water. 

If symptoms come from the intestine the bowel should 
be evacuated unless profuse diarrhcea has cleared it thor- 
oughly. A saline cathartic, or calomel followed by a sa- 
line cathartic, may be of service if the stomach can retain 
it. An enema may be given at any time for prompt effect 
or if cathartics cannot be retained. Both emesis and ca- 
tharsis are necessary for some severe cases. 

3. Rest for Digestive Tract. Well-nourished patients 
generally do best without food of any kind for from 12 
to 24 hours. Plain water or mineral water may be al- 
lowed in small quantities at short intervals. 

When beginning to feed it is wise to use liquids, such as 
beef tea, chicken broth, hot milk or orange juice, a few 
ounces every two hours. The nourishment should be in- 
creased in amount and in kind more or less rapidly ac- 
cording to the physician's estimate of the patient's diges- 
tive capacity. Hunger and a clean tongue generally indi- 
cate that considerable quantities of food can be assimi- 
lated; whereas a coated tongue and disgust for food mean 
the reverse. 

4. Symptomatic Treatment. 

(a) Nausea generally yields to rest and abstinence from 
food. Emesis is advisable for some cases. 

(6) Vomiting usually stops spontaneously when the 
stomach has been emptied. If it does not yield to rest and 
abstinence from food it may be checked sometimes by a 
teaspoonful of shaved ice with brandy, by a drop of Tr. 
of iodine in a teaspoonful of water, by I gr. (or 0.016 gm.) 
of cocaine hydrochloride dissolved in a teaspoonful of 
water, by £ gr. (or 0.008 gm.) of morphine sulphate ab- 
sorbed from the mouth, by other drugs, or by gastric lav- 
age. Food should be withheld entirely for from about 3 
to 12 hours after vomiting has ceased. Water should be 
allowed during this period in very small amounts if at all. 
Cracked ice may be sucked for thirst. 

When gastric disturbance lasts over a period of days, 



123 



salt solution must be administered in the form of enemata, 
by rectal seepage or by hypodermoclysis. Three pints in 
24 hours is enough. These measures and rectal feeding 
are very rarely needed in acute gastritis. 

Feeding should be resumed cautiously, using milk di- 
luted with mineral-water, lime-water, or carbonated water; 
or orange juice, or broth in teaspoonfuls every half hour. 
The quantity of nourishment should be increased and the 
intervals between feedings lengthened gradually. 

(c) Diarrhoea should not be checked until all old faecal 
matter has been discharged. If the diarrhoea persists in 
a mild form a few doses of about 15 grs. (or 1 gm.) of 
bismuth subnitrate may suffice to stop it. When diarrhoea 
is severe opiates are often required. A teaspoonful of 
paregoric may be prescribed after each loose movement. 
Morphine may be required subcutaneously. For other 
medicaments see p. 127. 

(d) Colic can be checked, when slight, by the applica- 
tion of heat to the abdomen and by rest and abstinence 
from food. 

Paregoric or other preparations of opium or morphine 
may be used for severe pain but they are contraindicated 
in full dosage until the intestinal tract has been cleared, 
and also when conditions which may require surgical in- 
terference cannot be ruled out. 



SIMPLE DIARRHCEA. 

DIAGNOSIS. 

Do not overlook the following diseases which may cause 
diarrhoea. 

1. Dysentery, bacillary or amoebic. 

2. Other infectious diseases, e.g., typhoid. 

3. Nephritis with colitis. 

4. Carcinoma of lower bowel. 

5. Faecal impaction with intermittent diarrhoea. 

6. Rectal diseases with tenesmus. 

7. Mucous colitis. 



125 



8. Reflex or nervous diarrhoea, e.g., due to chill, exophthal- 

mic goitre, or perhaps to anxiety. 

9. Habitual excess in eating and insufficient exercise. 

10. Irritating ingesta or imperfectly digested food. 

PRINCIPLES OF TREATMENT. 

Suit methods to severity, duration and persistence of 
symptoms: 

(a) Remove irritant, usually imperfectly digested food. 

(b) By means of a suitable diet avoid further irritation. 

(c) Limit peristalsis. 

(<Z) When there is toxemia, dilution and elimination of 
toxins is important (p. 69). 

METHODS. 

A. To Remove Irritant. Unless bowel has been thor- 
oughly evacuated prescribe a purge which will act quickly 
and ascertain that this result has been obtained before pro- 
ceeding to other kinds of medication. 

A saline, or castor oil, may be used. If these are vom- 
ited an enema may do good. It may be advisable to induce 
emesis (p. 121). Calomel generally acts well (p. 175). 

B. The Diet should be non-irritating; should leave lit- 
tle residue; and, preferably, should be digested high up. 

Eggs, broths and lean meats are well digested as a rule. 

Starches containing little cellulose may be preferred oc- 
casionally. 

Fats, fruits and coarse vegetables in general are to be 
avoided. 

Liquids should be bland and not cold. 

C. To limit peristalsis, (a) Rest, preferably in bed. 
(ft) Restriction of ingesta. Meals should be small and 

frequent. In severe conditions of short duration food and 
liquids may be forbidden entirely for a time. The length 
of time depends on the state of nutrition and tolerance of 
the patient. 

(c) Warmth, externally and internally, i.e., a warm 
room, avoidance of changes of temperature, a hot-water 
bag on abdomen and hot drinks. 



127 



MEDICATION. 

(a) Astringents. Bismuth subnitrate, fr. 10 to 20 grs. 
(or 0.65 to 1.3 gm.) every 2 to 8 hours. 

Acidum tannicum (U. S.), boiled green tea, red wine, or 
Tannalbin * may be tried. 

(b) Sedatives. Opiates are best, e.g. Tr. opii cainphor- 
ata (U. S.) "Paregoric," or Tr. opii deodorati (U. S.), or 
Misturse contra diarrhoeam (N. P.), as "Cholera mixture," 
" Squibb's Diarrhoea Mixture," and others, or " C. O. T. 
pill " t containing Camphor 1 gr. (or 0.065 gm.), Opium i 
gr. (or 0.016 gm.), and Tannic acid 2 grs. (or 0.13 gm.). 

CONSTIPATION. 

Constipation is a symptom seen in many diseases, some 
functional, some organic. The treatment should combat 
the cause or causes in the individual case. Hence, a clear 
understanding of every case is of prime importance. 

CLASSIFICATION OF CONSTIPATION. 

I. Obstructive Form. 

(a) Stricture. 

(b) Adhesions. 

(c) Pressure from tumor or pregnancy. 

(d) Ptosis with kink. 

(e) Acute obstruction. 

II. Spasmodic Form. 

(a) Mucous colitis. 

(b) Neurasthenia. 

(c) Lead poisoning. 

(d) Intra-abdominal or pelvic inflammation. 

(e) Fissure of anus. 

III. Atonic Form. 

Muscular weakness or general debility due to: 

1. Fevers. 

2. Anaemia. 

3. Cachexia. 

4. Senile debility. 



U. S. t. t Not official. 



129 

IV. Less common varieties of constipation are excluded 
from lack of space. 

Diagnosis of stricture, adhesions and ptosis or kink can 
seldom be made satisfactorily without bismuth x-rays, but 
x-ray evidence is often misleading. 

PRINCIPLES OF TREATMENT. 

A. Treat the cause while relieving the symptoms. 

B. Clear the intestinal tract thoroughly and keep it clear, 
including the rectum. 

C. Soothe or stimulate the bowel by suitable diet as re- 
quired. 

D. Improve habits if they are faulty. 

E. Use cathartics sparingly or not at all, and avoid undue 
irritation of the bowel by them. 

F. Prescribe sufficient liquid in definite quantity. 

G. Enjoin proper mastication of food and prescribe false 
teeth if needed. 

H. Instruct patient about regularity in defecation. 
I. Exercise or abdominal massage, unless contraindi- 
cated, may help sedentary persons. 

METHODS OF TREATMENT FOR OBSTRUCTIVE 
CONSTIPATION. 

(a) Stricture. Operation will generally be required. 
Palliation by means of " Russian Oil " by mouth, or by 
rectal injections of oil followed by cleansing enemata may 
be beneficial. 

(Z>) Adhesions. The palliative measures just mentioned 
may suffice. Exercise or massage may do good. Operation 
may be advisable. 

(c) Pressure. Palliate or operate according to circum- 
stances. 

(d) Ptosis. A suitable abdominal supporter may re- 
lieve. Other palliative measures and exercise or massage 
may help. Operation offers little hope of relief, as a rule. 

(e) Acute Obstruction. Prompt operation is imperative. 

METHODS FOR SPASMODIC CONSTIPATION. 
Mucous Colitis. 1. Non-irritating diet composed chiefly 
of carbohydrate with a moderate amount of fat and a little 



131 

easily assimilable proteid. Avoid foods rich in cellulose, 
acids, spices, tea, coffee and alcoholic beverages. 

The following list of suitable foods is hot complete, and 
should not be followed too closely in all cases. The experi- 
ence of the patient may be valuable. Fresh milk, cream, but- 
ter, sugar, rice, macaroni, sago, tapioca, strained oatmeal, 
cream of wheat, white bread or toast, potato, baked, boiled 
or mashed, junket, custard, blanc-mange, eggs, boiled, 
poached, scrambled or shirred, finely minced chicken or 
lamb, boiled tongue, or tender steak if it can be well 
chewed. Do not starve the patient. 

2. Bowels must be kept clear by injections of oil in the 
evening to be retained during the night, and by cleansing 
enemata, preferably of warm normal salt solution, every 
morning. 

3. Cathartics are particularly injurious to an irritated or 
inflamed mucous membrane and abdominal massage may 
do more harm than good. " Russian Oil " or Agar-agar may 
be useful, and are non-irritating. 

4. When the stools begin to appear normal the regimen 
can be relaxed. Finally, the patient can drop the injec- 
tions entirely and return to a mixed diet rich in cellulose 
and fruit to stimulate normal defectation. 

5. Colonic irrigations with or without appendicostomy 
may perhaps be tried in very obstinate cases. I have not 
seen them used and have never advised them for colitis 
secondary to chronic constipation. 

Constipation in Neurasthenia may take various forms, but 
it is generally attributable to reflex spasm, and is fre- 
quently associated with colitis. Every case should be care- 
fully classified and treated according to its nature. Any- 
thing which strengthens the patient or reduces his reflex 
excitability is likely to lessen the constipation. Moderate 
exercise and abdominal massage may do good. 

Injections of oil enemata, Russian Oil and Agar-agar, 
generally act well as in colitis. Be sure to keep the rectum 
clear. 

Lead Poisoning with Constipation. Antispasmodic medi- 
cation with morphine or atropine is required. 

Intra-abdominal or Pelvic Inflammation or Fissure of 



133 



the Anus may cause constipation by reflex spasm. Treat- 
ment demands removal of the cause by appropriate means. 

METHODS FOR ATONIC CONSTIPATION. 

Post-febrile constipation, being transient, may be treated 
with mild laxatives for convenience. 

Constipation in Anaemia, Cachexia, or Senile Debility. 
The patient's convenience should be considered, especially 
in ambulatory cases, or when the chance of ultimate cure 
is small. Nux vomica may be of service, and mild laxa- 
tives, glycerine suppositories, or enemata may be advised 
according to circumstances. Fsecal impaction should be 
guarded against and watery catharsis must be avoided. 
Massage may do good and mechanical support may aid de- 
fecation when the abdominal wall is weak. 

A diet, rich in cellulose, fruits, and sugar, may help to 
stimulate peristalsis. Graham bread, oatmeal, cracked 
wheat, green vegetables, beets, carrots, turnips, tomatoes, 
raw or stewed fruits and jams are particularly to be recom- 
mended for those who can digest them. 

METHODS USEFUL IN VARIOUS KINDS OF 
CONSTIPATION. 

I. Massage daily may be very beneficial. 
''Cannon-ball Massage." A heavy ball is necessary. A 

12- or 16-lb. "shot" (made for athletics) and covered with 
leather or strong cloth will serve. Once or twice daily the 
patient, lying on his back, should roll the shot repeatedly 
around the abdomen from the cascum along the course of 
the colon for 15 minutes before going to the toilet. 

II. Enemata. (a) In long-continued constipation the rec- 
tum may never empty itself completely (" dyschezia "). 
As a result the reflex to defecation may be lost. This re- 
flex can sometimes be regained after a course of injections 
of oil at night, followed by cleansing enemata in the morn- 
ing. Olive or linseed oil is suitable. From 4 to 6 oz. (or 
fr. 120 to 180 c.c.) should be used at each injection and the 
oil should be retained through the night. 

(b) Cleansing enemata of warm water with or without 



135 



the addition of Sod. bicarb, or of salt solution can be used 
when irritation of the mucous membrane is to be avoided. 

(c) Cold water, hot water, or soap suds and water are 
more potent than salt solution or warm water. 

(d) Strong enemata, consisting of glycerine fr. 1 drach. 
to 1 oz. (4 to 30 c.c); or of Sat. sol. of Mag. sulph., 
glycerine, and water aa 2 oz. (or 60 c.c.) can be used if re- 
quired. 

111. Laxatives should be used only in conjunction with 
suitable diet, abundant liquid (6 to 8 glasses of water daily) 
and hygienic habits. No one laxative suits all persons. 

(a) Fl. Ext. of Cascara sagrada can be used in doses of 
10 or 15 min. (or 0.6 to 1 c.c.) after meals, or in a single 
dose of fr. 10 min. to 30 min. (or 0.6 to 2 c.c.) at bed-time. 
When regularity of the bowels has been established the dose 
of Cascara can be diminished drop by drop until medicine 
is no longer required. 

(&) Prunes and Senna. Instruct patient to stew 3 dozen 
prunes with two tablespoonfuls of Senna leaves (enclose 
leaves in a cheese-cloth bag) , and to eat 10 prunes once or 
twice daily. When the bowels have been regular for a time 
the amount of Senna can be reduced until prunes only are 
taken. Later, the number of prunes can be reduced. 

(c) Russian Oil or Agar-agar may be tried. They act 
mechanically and do not irritate the intestines. 



CHAPTER V. 



DRUGS. 



FOREWORD. 

He who masters the use of a few good drugs will succeed 
better than he who tries many at random. 

Before prescribing a drug, let the indications for its use 
be clear. 

Prescribe drugs singly when expedient. 

Ascertain whether an idiosyncrasy to the drug you wish 
to prescribe is known to the patient. 

When a drug has been given, watch for its good or for its 
toxic effect. Increase dose until the one or the other is ap- 
parent. If neither results, change either the preparation or 
the drug. 

If toxic effects occur, omit the drug for a time and resume 
it later in smaller dosage or try a substitute. 

EXPLANATION. 

The purpose of the list which follows is to indicate the 
important drugs and the preparation of each believed to be 
the most generally useful. The dosage recommended is suit- 
able for the average adult and may require modification for 
the individual. 

Much useful information is contained in the " United 
States Dispensatory." It describes the drugs of the princi- 
pal pharmacopoeias, the preparations of the " National For- 
mulary," and many unofficial preparations. " New and Non- 
official Remedies " gives information about many proprie- 
tary drugs. The writer's information about patents and 
trademarks was derived from this book. It is published and 
sold by the American Medical Association. 

137 



139 



ABBREVIATIONS. 

U. S. United States Pharmacopoeia, 8th Rev. 

Br. British Pharmacopoeia. 

N. F. National Formulary. 

U. S. p. and t. United States patent and trademark. 

N. N. R. New and Nonofficial Remedies, 1914. 

U. S. D. United States Dispensatory, 19th Ed. 

SYNOPSIS OF DRUGS. 

i. SALVARSAN.* 

Action. Kills certain pathogenic organisms in the living 
body. It may irritate the kidneys or liver but seems to have 
no toxic effect per se for other organs. 

Elimination. Excretion rapid, chiefly in urine and faeces. 
When the excretory organs act normally, most of the drug 
Is eliminated on the first day and nearly all within three or 
four days after an intravenous injection. 

Toxic effects. 1. Signs of renal irritation or diminution 
of kidney function. 

2. Jaundice. 

3. Erythema. 

4. Hyperemia and swelling at the site of syphilitic lesions; 
i.e., " Herxheimer reaction." To this group probably belong 
many of the dangerous symptoms arising within three days 
of the injection. Among them may be mentioned headache, 
vomiting, earache, syncope, convulsions and coma. 

5. Fever developing gradually after a day or two may re- 
sult from rapid destruction of spirochaetae. 

Accidents or errors which may cause severe symptoms or 
death: 

1. The " water-error," i.e., contamination of the distilled 
water (used for solution) with bacteria living or dead; or 
with chemical impurities from the distilling apparatus. 
Symptoms often attributed to water-error are rigor, rapid 
rise in temperature, gastro-enteric disturbances, etc.f 



* U. S. p. and t, 

t There are those who believe that the symptoms attributed to the 
water-error " are due to other causes, e.g., overdosage. 



141 

2. Impurity of NaCl or of NaOH used in the solution. 

3. Oxidation of the Salvarsan may be followed by signs of 
arsenical poisoning, gastro-enteric disturbance, peripheral 
neuritis, paraplegia, etc. 

4. Accidental use of an acid instead of an alkaline solution. 
The former is 10 times more toxic than the latter. 

5. Errors in technic of injection; may result in venous 
thrombosis and pulmonary embolism. 

G. Use of Salvarsan in unsuitable cases. 

7. .Lack of preparation, or of after-care of the patient. 

8. Excessive dosage for the individual under existing cir- 
cumstances, or too early repetition of dose. 

9. Combined effect of various factors above mentioned. 

10. Neurorecurrence. It appears after weeks or months 
and is a recurrence of syphilis, not an effect of Salvarsan. 

Indications. Suitable cases of syphilis, relapsing fever, 
yaws, and various other diseases. Salvarsan is not danger- 
ous when used wisely and with the best technic. 

Contraindications are relative rather than absolute. The 
use of Salvarsan is particularly dangerous when the pa- 
tient has: 

1. Aneurism, coronary sclerosis, myocarditis, evidence of 
angina pectoris, or other severe lesions of the circulatory 
system. 

2. In non-syphilitic nephritis. 

3. In diseases of the liver, pancreas, or adrenal glands. 

4. When there is advanced degeneration of the nervous 
system. 

5. Profound anemia, or pronounced cachexia not due to 
syphilis. 

6. Severe pulmonary lesions, or marked physical weakness 
from any cause. 

Caution is advisable when there are: 

1. Syphilitic lesions of the central nervous system, or 
when their presence is indicated by changes in the spinal 
fluid or suggested by slight symptoms. 

2. In the secondary stage of syphilis. 

3. When the patient is alcoholic. 

4. Shortly after fatigue or exertion. 



143 



5. When, excess of any kind, work, or travel, cannot be 
prevented for a time after the injection. 

G. In old age, or when there is advanced arteriosclerosis. 

Administration. An infusion apparatus consisting of a 
glass receptacle with an opening at the bottom, a rubber tube 
provided with a glass window at the lower end, a clamp 
and a needle will suffice. At the Massachusetts General Hos- 
pital salt solution is used to establish the flow. When 
nearly all the salt solution has left the receptacle the Sal- 
varsan is poured in. Salt solution is poured in again to 
clear the needle before it is withdrawn. Care is taken to 
prevent the entrance of air into the vein. About five min- 
utes is allowed for the passage of the Salvarsan into the 
vein, and the rate of flow is regulated by the height of the 
receptacle. 

This operation requires strict asepsis at every step. 

Dose. Speaking of the use of Salvarsan in syphilis, Ehr- 
lich says: " The dose depends entirely on the type and stage 
of the disease." Ordinarily, fr. 0.1 to 0.6 gm.* is used at in- 
tervals of from 5 to 10 days. In rare instances smaller or 
larger doses may be tried. 

Caution. When danger is to be feared begin treatment 
with a series of very small doses at long intervals, or an 
energetic course of Mercury. The combined use of large 
doses of Salvarsan and of Mercury at the same time is be- 
lieved to be unsafe. 

Note. — Alternate courses of Salvarsan and of Mercury are 
to be recommended for syphilis. 

NEOSALVARSAN. 

Action. Like that of Salvarsan but less powerful in equal 
dosage. 

Toxic Effects. Similar to those of Salvarsan but milder 
with equal dosage. 

Indications. It may be preferred to Salvarsan because 
easier to prepare, or when toxic effects are feared. 

Contraindications. As for Salvarsan. 

* The full dose of 0.6 gm. is being used less frequently, and smaller 
doses more frequently now at the Mass. Gen. Hosp. 



145 

Administration. Use immediately, because contact with 
air causes rapid decomposition. Do not mix the drug until 
everything is prepared and the needle already in the vein. 

Dose. 0.9 gm. of Neosalvarsan contains the same quan- 
tity of arsenic as 0.6 gm. Salvarsan. 

Preparation of Alkaline Solution of Salvarsan for Intra- 
venous Use. 

Printed instructions for preparing the solution are pro- 
vided with the drug. 

Technic of the Massachusetts General Hospital. 

1. Everything used for preparing the solution is steril- 
ized beforehand, and is handled under strictly aseptic pre- 
cautions. 

2. The solution is mixed in an 8-oz. bottle which should 
have a glass stopper. The bottle is graduated for 100 and 
for 200 c.c. Similar ungraduated bottles should be used for 
dispensing. 

3. The drug is dissolved in the mixing bottle by hard 
shaking with about 50 c.c. of 0.6 % salt solution instead of 
distilled water. Solution takes place rapidly without the aid 
of beads. 

4. To a dose of 0.6 gm. of Salvarsan thus dissolved 5 c.c. 
of normal NaOH solution is added and the mixture is again 
shaken until perfectly clear. Salt solution is then added to 
make 200 c.c; the dispensing bottle is rinsed with the solu- 
tion; the solution is filtered back into the dispensing bottle, 
and after insertion of the stopper, the neck of the bottle is 
covered with sterile gauze, which is held in place by a pin. 
The drug is then ready for use. 

Salvarsan may decompose within a few hours. It should 
be kept cool until needed, and should then be warmed only 
a little. 

List of Things Required for Preparing Solution. 

1. Burette graduated to c.c, containing normal NaOH 
solution. 

2. Flask of 0.6% NaCl solution. 



147 



3. Glass funnel and filter paper. 

4. One graduated and one plain 8-oz. bottle having glass 
stoppers. 

5. Basin of antiseptic containing also the ampule of Sal- 
varsan, a file and a pin. 

6. Sterile sheet and sponges. 

2. HYDRARGYRUM. 

" Mercury." 

(a) Hydrargyri salicylas.* "Neutral mercuric salicyl- 
ate." 

(&) Hydrargyri chloridum corrosivum (U. S.). "Corro- 
sive sublimate," " Bichloride of mercury." 

(c) Unguentum hydrargyri t (U. S.). "Mercurial oint- 
ment." 

(d) Hydrargyri iodidum flavum (U. S.). " Protiodide or 
yellow iodide of Mercury." 

Action of the above preparations is essentially the same: 
anti-syphilitic, local irritant, and antiseptic. 

Elimination. Chiefly by intestines and kidneys; also in 
saliva. Excretion is slow. 

Toxic Effects: Acute Poisoning: stomatitis, salivation, 
renal irritation, diarrhoea, abdominal pain and gastric dis- 
turbance. 

Chronic Poisoning : cachexia, anemia, etc. 

Indications: Syphilis. The choice of a mercurial prepara- 
tion depends on the stage and severity of the disease, the 
condition of the patient, and the circumstances under which 
the treatment is to be carried out. Each of the four prep- 
arations mentioned above has advantages lacking in the 
others. 

Contraindications. Nephritis unless luetic, cachexia, ane- 
mia. 

Administration and Dose. 

(a) Hydrargyri salicylas: nearly insoluble; single dose 



* Not official in U. S. There is also a basic salicylate of mercury 
(Merck). It is used at the Massachusetts General Hospital. 

t Conts. about 50% of Mercury by weight. Ung. Hydrarg. Dil. 
(U.S.), "Blue ointment," conts. about 33% of Mercury. 



149 



fr. 10 to 15 min. (or 0.6 to 1 c.c.) of a 10 % solution of the 
drug in Petrolatum; repeat in from 5 to 10 days. Inject 
into the gluteal muscle. Use a platinum needle. 

(&) Hydrargyri chloridum corrosivum: soluble; single 
dose fr. 7 to 15 min. (or 0.5 to 1 c.c.) of a 1 % solution of 
the drug in a 10 % watery solution of Sodium chloride; 
repeat in 1 or 2 days. Inject into the gluteal muscle. Use 
a platinum needle. 

(c) Unguentum hydrargyri: administer by inunction. 
Dose fr. I to 1 drach. (or 2 to 4 gm.). Efficiency depends 
much on thoroughness of application. 

(cl) Hydrargyri iodidum flavum; administer in pills by 
mouth. Dose: £ gr. t.i.cl. (or 0.013 gm.) and upward, in- 
creasing" gradually until the first signs of intolerance appear. 
Then reduce dose by half and continue. 

Caution. When mercurials are given, the mouth must be 
kept scrupulously clean to avoid stomatitis. Teeth should 
be brushed and throat gargled after every meal. If there 
is pyorrhoea alveolaris, the gums may be scrubbed with cas- 
tile soap or swabbed daily with a 1 % solution of Potassium 
permanganate, applied with cotton stick; also rinse or spray 
mouth with Hydrogen peroxide. When giving the Pro- 
tiodide of Mercury and Sodium or Potassium iodide also, 
give the Protiodide a. c. and the Potassium iodide p. c. to 
prevent formation of the Biniode of Mercury. When using 
large doses of any mercurial, the bowels should be kept 
clear, and the food should be readily digestible, nutritious 
and ample in quantity. 

Note. — The reader is advised not to use Mercury in large 
doses or by injection unless familiar with the details of its 
administration, dosage and indications. Gottheil gives an 
excellent account in Forchheimer's " Therapeusis of Inter- 
nal Diseases." 

3. POTASSII IODIDUM. (U.S.) 
"Iodide of Potash." 

Properties. White, crystalline, very soluble in water. 
Action. 1. Causes disappearance of gummata; but a 



151 

lesion which disappears while iodides are being taken is not 
necessarily syphilitic. 

2. Increased fluidity of mucus in respiratory tract.* 

3. Tends to lower blood-pressure when high.* 

4. Seems to increase thyroid activity. 

Elimination. Rapid, chiefly in urine as salts, partly in 
saliva.* 

Toxic Effects: Acute: Acne, erythema, and other seri- 
ous skin lesions, catarrh of respiratory organs, gastric dis- 
turbances, delirium, etc. Chronic: loss of weight, nervous- 
ness, anemia. 

Indications. 1. Late stages of syphilis. 

2. Bronchitis with sticky expectoration. 

3. Empirically in arteriosclerosis, asthma, lead poisoning, 
simple goitre, and many other conditions. 

Contraindications. Acute renal irritation, acute inflam- 
mation of the respiratory tract, and " hyperthyroidism." 
It may be harmful in phthisis. 

Administration. 1. For syphilis, fr. 10 to 20 grs. (or 0.6 
to 1.3 gm.) t.i.d.p.c. in milk. For syphilis of central 
nervous system, increase dose rapidly until benefit or io- 
dism results. One hundred grains (or 6.5 gm.) t. i. d. is 
large enough dosage. The sat. sol. in water is convenient: 
1 min. = 1 gr. or 0.065 gm. 

2. As expectorant give fr. 5 to 10 grs. (or 0.3 to 0.6 gm.) 
t. i. d. p. c. well diluted. 

3. For empirical action use small doses. 

Substitutes. For syphilis: other preparations of Iodine, 
Mercury, or Salvarsan. 
As expectorant: Ammonium chloride. 

4. DIPHTHERIA ANTITOXIN.f 

Action. Curative in diphtheria. 

Absorption. It is absorbed slowly from the subcutaneous 
tissues, the process lasting for several days. 



* Bastedo. 

t Manufactured by Departments of Health and by pharmaceutical 
firms. It can be obtained from the State Board of Health in Massa- 
chusetts free of charge. 



153 



Toxic Effects. Urticaria, erythema, joint-pains, etc. 
Indications. Clinical diphtheria; and for those exposed 
to diphtheria. 

Contraindications. Never absolute. Dangerous in suffer- 
ers from asthma, particularly horse asthma. When a pa- 
tient has received an immunizing dose, and two weeks or 
more thereafter develops diphtheria, the possibility of ana- 
phylaxis must be considered, but the risk is not great.* 

Administration. By injection into the loose subcutaneous 
tissues of the abdominal wall or below the angle of the 
scapula- 
Dose. The dose should be gauged according to the sever- 
ity of symptoms, duration of illness, and extent and loca- 
tion of the membrane.* Large doses are indicated when 
the larnyx, trachea, nasopharynx or nose is much involved, 
and especially in septic diphtheria. 

Therapeutic dose for adults, fr. 5000 to 20,000 units. For 
immunization, fr. 1000 to 1500 units. 

5. MORPHINE SULPHAS. (U. S.) 

" Morphine " or " Morphia." 

Properties. White, crystalline, soluble in about sixteen 
parts water; less soluble in alcohol. 

Action. 1. Diminishes sensibility to lasting impressions 
and stimuli., (Sollmann.) 

2. Relieves pain. 

3. Slows respiration and heart-action. (Bastedo.) 

4. Diminishes metabolism. 

5. Diminishes peristalsis; therefore, constipating. 

6. In acute cardiac dilatation gives relief. 

7. In colic or intestinal spasm it may act as a cathartic. 
Elimination. Chiefly by gastro-intestinal tract. Some is 

oxidized in the body. 

Toxic Effects. 1. Somnolence or stupor. 

2. Respiration very slow and may become shallow and 
irregular (Cushny). 



* Darlington: " Therapeusis of Internal Diseases," Vol. II, Forch- 
heimer. 



155 



3. Pupillary contraction. 

4. Flushing or cyanosis of face. 

5. Retention of urine. 

6. During recovery from drug nausea is common. 

7. Death results from depression of respiratory center. 
Indications. Acute conditions with, — 

1. Severe pain. 

2. Discomfort preventing sleep. 

3. Acute cardiac insufficiency. 

4. Internal hemorrhage (gastric, pulmonary, intestinal). 

5. Persistent vomiting. 

Contraindications.* 1. Danger of forming habit. In 
chronic or recurring non-fatal diseases, and in conditions 
which can be relieved by milder means, use morphine with 
caution if at all. 

2. When bronchial secretion is profuse, morphine may 
prevent necessary expectoration: see pneumonia, p. 87. 

3. Idiosyncrasy: causes excitement, vomiting, depression. 
Administration. For urgent conditions give subcutane- 

ously in the dose of fr. | to 1 gr. (or 0.008 to 0.032 gm.), 
with or without atropine sulphate, fr. y 200 to y 12 Q gr- (or 
0.00032 to 0.00052 gm.). Morphine is generally given by 
mouth in tablet, in watery solution, or in a mixture. 
Morphine can be absorbed from the mouth and will then act 
more quickly than if swallowed. Atropine given with mor- 
phine tends to diminish the gastric disturbance which may 
follow. Atropine produces toxic symptoms if repeated 
often. 

Substitutes. Opium in pill, as tincture, or in suppository. 

1. Pilulse opii (U. S.) : conts. opium 1 gr. (or 0.065 gm.) 
( = morphine $ gr. or 0.008 gm.). 

2. Tinctura opii deodorati (U. S.). Dose fr. 5 to 15 m. 
(or 0.3 to 1 c.c). 



* Codman believes that morphine after abdominal operations may in- 
duce gastric dilatation ; and Bastedo says it should not be used when 
there is " much depression of respiration, as in edema of the lungs, 
Cheyne-Stokes breathing, and some cases of pneumonia," or in " acute 
dilatation of the stomach or bowels." " It should be employed cau- 
tiously in nephritis, especially if there is any uremic tendency," and 
in " infancy and old age." 



157 

3. Tinctura opii camphorata (U. S.) — "Paregoric." 
Dose for adult fr. 1 to 4 dr. (or 4 to 16 c.c). 

4. Codeinse sulphas (U. S.). Dose J to \ gr. (or 0.008 to 
0.032 gm.). 

5. Hyoscinae hydrobromidum (U. S.). Dose fr. y 150 to 
Moo S r - (° r 0-00033 to 0.00065 gm.) subcutaneously. Com- 
bined with morphine it may act better than either. 

6. TINCTURA DIGITALIS. (U. S.) 
" Tincture of Digitalis." 

Action. 1. Increases force of cardiac systole. 

2. Lengthens diastole and slows heart action. 

3. Raises blood-pressure if pressure is low. 

4. Promotes diuresis when there is dropsy. 
Absorption slow; therefore, 24 hours or more is required 

for result. Action may be cumulative because excretion is 
slow. 

Toxic Effects. Tachycardia or bradycardia with irregu- 
larity, heart-block, pulsus alternans, fall of blood-pressure, 
oliguria, vomiting, headache. > 

Indications. Myocardial insufficiency in general, with or 
without valvular disease. Almost useless in circulatory 
weakness resulting from vascular dilatation or from deple- 
tion. 

Tachycardia, per se, does not call for digitalis. 

Contraindications. When increase of blood-pressure 
would be dangerous, e.g., cerebral hemorrhage. 

When heart-block is developing use digitalis cautiously 
if at all. 

Administration. Prescribe with water p. c. 

Ordinary dose: fr. 5 to 20 m. t.i.d. (or 0.32 to 1.3 c.c). 
If preparation is weak, higher dosage may be required. 
Tincture should be made from active leaves and should be 
fresh. 

When quick action is required, fr. 20 to 30 min. (or 1.3 
to 2 c.c.) may be injected intramuscularly. It is a local 
irritant. 

To prevent cumulative effect, keep bowels free. 



159 



Substitutes. 1. " Digipuratum." * Dose fr. 1 to 4 tab- 
lets in twenty-four hours. Each tablet contains 1£ grs. 
(or 0.097 gm.) of digipuratum and is about equal in 
strength to 15 m. (or 1 c.c.) of the most active tincture 
of digitalis. Its therapeutic action is like that of the 
tincture but the effect comes more quickly and digestive 
disturbance is rare. This drug should act in fr. 12 to 24 
hours. 

" Digipuratum-solution " can be obtained in vials, each 
containing 1^ grs. (or 0.097 gm.) of the drug, and this dose, 
or half of it, "can be injected intramuscularly. The effect 
can then be expected in about half an hour. The same 
preparation acts in about 10 minutes when used intraven- 
ously. The injection should be given very slowly. Single 
dcses of fr. | to 1^ grs. (or 0.05 to 0.097 gm.) can be used 
intravenously. 

2. Strophanthinum (U. S.).f Action on heart is like digi- 
talis but effects are sudden and profound. Death may re- 
sult if the patient has taken any preparation of the digi- 
talis group within one week. On account of local irritant 
action strophanthin should be used intravenously, and to 
avoid shock the injection should be given very slowly over 
a period of not less than 5 minutes. Dose fr. 0.0005 to 
0.001 gm. 

7. NITROGLYCERIN.* 
" Glonoin," " Trinitrin." 

Action. Lowers blood-pressure by dilating peripheral ves- 
sels. Acts within a few minutes; effect lasts about % hour. 
In the presence of hypertension diuresis may result. 

Toxic Effect. Flushing, sense of fulness in head, throb- 
bing headache, faintness. Reduction of urinary output. 



* U. S. p. and t. ; expensive. Ceesar & Loretz powdered digitalis 
leaves are excellent and less expensive. Parke, Davis & Co.'s Tincture 
is good. 

t Boehringer's is good. It is marketed in vials containing 0.001 gm. 
of the drug in solution. 

t Official only in the form of Spiritus glycerilis nitratis (U.S.), 



161 



Lwhen due to high pressure. 



Indications. Angina pectoris. 
Cardiac embarrassment 
Headache. 

Contraindications. Low blood-pressure. 

Administration. Tablet triturate. For quick absorption 
the tablet should be chewed and not swallowed. 

Ordinary dose, y wo gr. (or 0.00065 gm.) may be repeated 
frequently unless toxic symptoms result. 

For some cases % 00 gr. (or 0.00032 gm.), or y 50 gr. (or 
0.0013 gm.) is better. Larger doses may be required. 

Substitutes. 1. Amylis nitris (U. S.). " Amyl nitrite." 

Dose 3 to 5 min. (or 0.18 to 0.3 c.c). 

Acts very rapidly. Effect very transient. 

May act when nitroglycerin fails. 

Put up in "pearls" containing 3 or 5 min. (0.2 or 0.3 
c.c). 

Break pearl and inhale from handkerchief. 

Pearls * should break easily but not spontaneously. 

2. Sodii nitris (U. S.). "Sodium nitrite." 

Action like nitroglycerin, but lasts longer. 

Best prescribed in watery solution. 

Dose, 2 grs. (or 0.13 gm.). 

8. "THEOBROMINE SODIUM SALICYLATE." t 

Properties. White pwd. v. sol. in water, taste unpleas- 
ant, turn brown on exposure to air. 

Action. Diuretic; slightly irritating to the kidneys. Ef- 
fect is produced in from twelve to forty-eight hours; lasts 
for from two to three days. 

Toxic Effect. Vomiting. 

Indications. Cardiac dropsy. (Useless or nearly so in 
pure renal dropsy.) 

Contraindications. Acute nephritis. 

Administration. In capsules or in a cachet p. c. 

Dose, 15 grs. (or 1 gm.) 4 i. d, If no result after 48 
hours, double dose. 



* Allen & Hanbury's are good. 

t A double salt of theobromine-sodium and sodium salicylate. It is 
official in Germany, (N.N.R.). " Diuretin " is the " trade name " of 
a similar proprietary remedy. 



163 



Substitutes. 1. Fluidextractum apocyni (U. S.) or 
" Canadian hemp." Action diuretic and like that of digi- 
talis but milder. Dose, fr. 5 to 15 m. (or 0.3 to 1 c.c). 
Effects occasionally dangerous. Better prescribed as a 
fresh infusion (Wheatley) corresponding dose, fr. 5 to 10 
min. (or 0.3 to 0.6 c.c). 

2. Theophylline.* Dcse fr. 3 to 6 grs (or 0.2 to 0.4 
gm.) t.i.d. in powder with water or in capsule. 

3. If kidneys are sound, Calomel may be used in the dose 
of 3 grs. (or 0.2 gm.) every four hours for from twenty-four 
to forty-eight hours or even longer. To reduce danger of 
salivation take precautions described under Hydrargyrum. 

9. MAGNESII SULPHAS. (U. S.) 
" Salts," " Epsom Salts " or " Bitter Salts." 

Properties. Colorless, crystalline, very soluble in water, 
taste bitter. 

Action. Hydrogogue purge. Ordinarily, it is not ab- 
sorbed. 

Toxic Effects. Gastric irritation and vomiting. If given 
in concentrated solution it may be absorbed and may then 
cause severe poisoning characterized by oliguria, hematuria, 
slow respiration, paralysis of the intestines, extreme weak- 
ness and collapse.! The urine in poisoning shows a very 
high specific gravity owing to the excretion of the drug 
by the kidney. These effects are rare. 

Contraindications. Weakness, emaciation, vomiting, 
menstruation, pregnancy. 

Administration. Most easily taken in a cup of black cof- 
fee and most effective when taken 1 hour before breakfast 
or when the stomach is empty. 

Dose. From * to 1 oz. (or 15 to 30 gm.) followed by half 
a glass of water. Small doses with much water can be 
used for mild catharsis. 

Substitutes. 1. Croton oil, fr. 1 to 3 min. (or 0.06 to 0.2 



* Not official. Under the name of " Theocin " it bears U. S. 
and t. (N.N.R.). 

f Boos: Jr. A.M.A., Dec. 10, 1910. 



165 

c.c.) in pellet of butter. If placed on the back of the tongue 
of an unconscious patient it will be swallowed. 

2. Pot. bitartrate and Comp. jalap, pwd. aa drach. 1 (or 
4 gm.). 

3. Elaterium (Br.) J gr. (or 0.016 gm.) in tablet. 

4. " Ten-ten," calomel and jalap, aa grs. 10 (or 0.65 
gm.). 

10. QUININE SULPHAS. (U. S.) 
" Quinine." 

Properties. White, cryst., slightly sol. in water, taste 
very bitter. 

Action. Specific for malaria, antipyretic; readily ab- 
sorbed, and rapidly eliminated in urine. 

Toxic Effects. Tinnitus, headache, vomiting, erythema; 
occasionally renal irritation, amblyopia, or cardiac depres- 
sion. 

Indications. Malaria. 

Contraindications. Idiosyncrasy but patients are fre- 
quently mistaken in believing they cannot take quinine. 

Administration. In capsule p. c. Dose, fr. 5 to 10 grs. 
(or 0.32 to 0.65 gm.) from 2 to 4 i. d. Larger doses may 
be required. 

Substitute. 1. Quininse hydrochloridum (U. S.) * fr. 7 to 
10 grs. (or 0.5 to 0.65 gm.) daily, dissolved in water and 
given intramuscularly, or 30 grs. (or 2 gm.) in enema 
(Manson). 

2. Craig recommends for pernicious malaria intramuscu- 
lar injections of Quinine bihydrochloride t grs. 7£ (or 0.5 
gm.) dis. in water, 15 min. (or 1 c.c.) and repeat every 4 
hours if necessary. 

3. Quinine and urea hydrochloride t is more soluble and 
has been recommended in recent years. It is much used 
in surgery as a local anaesthetic and can be obtained in 
sterile solution in vials. 



* Soluble in 35 parts water. 
t Not official. 



167 



ii. SODII SALICYLAS. (U. S.) 

Properties. A white powd. sol. in water, taste sweetish 
and saline. 

Action. Analgesic, antipyretic, and diaphoretic. It has a 
curative effect in some forms of rheumatism. It increases 
nitrogen elimination in the urine and acts as a cholagogue 
and diuretic. It is readily absorbed and is eliminated by 
the kidney. 

Toxic Effects. Tinnitus, headache, vomiting, erythema, 
delirium and gastro-enteric disturbance. It is slightly ir- 
ritating to the kidneys and unless given with alkali may 
cause albuminuria. Very large doses may cause drowsiness 
or coma. 

Indications. Rheumatic fever and various forms of 
" rheumatism." Useless in the gonorrheal and in some 
other types of arthritis. It may be tried in large doses for 
infectious endo- or pericarditis or for chorea. 

Contraindication. Acute nephritis or idiosyncrasy. 

Administration. In tablet or capsule followed by a full 
glass of water unless the heart be insufficient. If large 
doses are to be used prescribe also enough sodium bicar- 
bonate to render the urine alkaline and see that the bowels 
be kept free. 

Dose. For rheumatic fever, 10 grs. (or 0.65 gm.) of so- 
dium salicylate every hour until the patient is relieved of 
pain; then 10 gr. (or 0.65 gm.) every 4 hours until convales- 
cence has been established; then fr. 20 to 30 grs. (or 1.3 
to 2 gm.) daily for a month or more to prevent relapse. If 
toxic effects occur the medicine must be omitted until they 
pass off. It can then be resumed in smaller dosage or in 
different form. A vehicle, such as essence of pepsin, may 
be helpful. For mild cases of arthritis smaller doses may 
be sufficient. In chronic " rheumatism " fr. 5 to 10 grs. 
(or 0.3 to 0.65 gm.) taken fr. 2 to 4 1 d. may promote com- 
fort. 

Substitute. 1. Salicinum. (U. S.) Action and uses like 
sodium salicylate but weaker and causes less gastric dis- 
turbance. 

2. Oleum gaultheriae. (U. S.) "Oil of wintergreen." 



169 



Should tie given in milk, or in capsule. Dose, fr. 15 to 30 
min. (or 1 to 2 c.c). 

3. Aspirin: * Acetylsalicylic acid. Incompatible with 
heat, moisture, alkalies, their carbonates and bicarbonates 
(N. N. R.) Dose as for sodium salicylate. 

12. HEXAMETHYLENAMINA. (U. S.) t 

Properties. Crystalline, readily sol. in water. 

Excretion. Chiefly in the urine in the form of ammonia 
and formaldehyde or unchanged. 

Action. When formaldehyde J is set free it acts as a uri- 
nary antiseptic. When the drug is excreted unchanged, 
as often happens, it is inefficient. It acts only in an acid 
urine. 

Toxic Effects. Renal irritation and hematuria, painful 
micturition and pain in the region of the bladder. 

Indications. Especially useful in typhoid fever to pre- 
vent bacilluria and cystitis. It may act well in other cases 
of cystitis or pyelitis. 

Contraindication. Acute nephritis. 

Administration. In capsule or tablet. Dose from 5 to 10 
grs. (or 0.3 to 0.6 gm.) t. i. d. with a full glass of 
water. When the urine is alkaline or neutral acid sodium 
phosphate can be prescribed to change its reaction, but this 
drug should not be administered with Hexamethylenamine 
because they are incompatible (Bastedo). 

VALUABLE DRUGS. 

13. Pilulae ferri carbonatis. (U.S.) " Blaud's Pill." 

Action: rubifacient, slightly constipating, turns stools 
black. 

Used especially in chlorosis and secondary anemias. 

Dose: pills of 5 grs. each (or 0.3 gin.*) ; fr. 1 to 2 t. i. d., 
p. c. 



* U. S. p. and t, 

t " Urotropine," "Formin," and " Aminoform " are proprietary 
names applied to Hexamethylenamina. (N.N.R.) 
? May give Fehling's reaction. (Bastedo.) 



171 

Substit. 1. Tr. ferri chloridi. (U. S.) Dose, fr. 5 to 30 
m. (or 0.3 to 2 c.c.) taken through a glass tube. 

2. Liquor ferri et ammonii acetatis. (U. S.) " Basham's 
mixture." Dose, 1 dr. (or 4 c.c). 

14. Sulphonethylmethanum. (U. S.) "Trional." 
Action: hypnotic, sol. in 195 water, more soluble in al- 
cohol. 

Toxic Effect: somnolence and mental and physical depres- 
sion. 

Used for insomnia, sometimes for alcoholic delirium. 

Dose: for sleep, fr. 5 to 15 grs. (0.3 to 1 gm.) in powd. 
by mouth. Larger doses may be used for delirium. 

Prescribed in powder by mouth with water or in sol. by 
rectum. 

Substit. "Veronal." (U. S. pat.) Dose, as for trional 
in powd. or tab. 

15. (a) Sodii bromidum. (U. S.) "Sodium bro- 
mide." 

(b) Potassii bromidum. (U. S.) "Potassium 
bromide." 

Action: Mild sedative, lessens reflex excitability. Slightly 
irritating to the stomach. 

Toxic Effect: Vomiting, acne, coryza, somnolence. 

Used for nervousness, insomnia, epilepsy, and to ward 
off alcoholic delirium. 

Dose: Usually fr. 5 to 15 grs. (or 0.3 to 1 gm.) t. i. d., 
or a single dose at night for sleep. 

Much larger doses may be required for epilepsy and for 
alcoholic patients. 

Prescribed in watery solution by mouth well diluted and 
p. c, or, occasionally, by rectum. 

16. Acetphenetidinum. (U. S.) " Phenacetin." * 
Action: analgesic, antipyretic, mild diaphoretic, and seda- 
tive. 

Toxic Effect: circulatory depression. 

Used especially for migraine and occasionally for other 
painful conditions. 

Dose: fr. 5 to 15 grs. (or 0.3 to 1 gm.) in tab. or pow- 



Bayer's is the best. 



173 

der. A small dose may be repeated in an hour or more if 
necessary. Prescribe with caffein citrate, 1 gr. (or 0.065 
gm.). 

17. Pulvis ipecacuanhae et opii. (U. S.) "Dover's 
Powder." 

Action: Mild opiate: hypnotic, sedative, diaphoretic, an- 
tipyretic and analgesic; slightly constipating. 

Toxic Effect: When stomach is irritable vomiting may 
result. 

Used generally in single dose in the evening for malaise 
or insomnia in acute infections such as " grippe," tonsillitis, 
or the exanthemata. 

Dose: fr. 10 to 15 grs. (or 0.6 to 1 gm.) in pwd. by 
mouth. 

18. Codeinae sulphas. (U. S.) "Codeine." 

Action: mild opiate and sedative. Slightly constipating. 
Toxic Effect: vomiting, generally on following day. 
Used to allay unproductive cough. 

Dose: fr. i to 4 gr. (or 0.008 to 0.032 gm.) in tablet, by 
mouth. 

19. Sodii bicarbonas. (U.S.) "Soda." " Saleratus." 
Action: antacid. 

Toxic Effect: gastric disturbance, not poisonous. 

Used for " hyperacidity," in acidosis, and in acid poison- 
ing; to render urine alkaline; and with salicylate in acute 
rheumatism. 

Dose: fr. J to 1 dr. (or 2 to 4 gm.) 3 or 4 i. cl. with water 
by mouth. Larger doses may be required in acidosis. 

20. Bismuthi subnitras. (U. S.) "Bismuth." 
Action: mild astringent and antacid. Combines with 

H,S in intestine to form a black, insoluble sulphide. 

Toxic Effect: none with therapeutic dose. 

Used for diarrhoea, " hyperacidity," peptic ulcer, and for 
intestinal fermentation. 

Dose: for diarrhoea fr. 10 to 20 grs. (or 0.65 to 1.3 gm.) 
repeated after each loose movement. For peptic ulcer * 
doses of 1 dr. (or 4 gm.) are used a. c. to coat the ulcer and 



Use a pure preparation: e. g., Squibb' 



175 



to relieve distress. Prescribed in powd. by mouth with 
water. 

21. Hydrargyri chloridum mite. (U.S.) "Calomel." 
Action: Mild purgative and supposed intestinal antisep- 
tic. Diuretic. Antisyphilitic. 

Toxic Effects: renal irritation, stomatitis, etc. (p. 149). 
Use and Dose: 1. as a mild purge, either in the dose of 
T \ gr. (or 0.006 gm.) every 15 m. for 8 or 10 doses and 
followed by a mild saline cathartic 1 hour after the last 
dose, or fr. 1 to 3 grs. (or 0.065 to 0.2 gm.) can be taken 
in single dose at night and the saline on the following 
morning. 

2. As a diuretic: 3 grs. (or 0.2 gm.) every 4 hours for 
fr. 24 to 48 hours or until diuresis begins. When using 
this dose the usual precautions against poisoning must be 
taken (p. 149). Prescribe in tablet. 

3. Calomel is preferred by many to salicylate of mercury 
for the treatment of syphilis by injection. 

22. Oleum ricini. (U. S.) "Castor oil." 

Action: mild purgative; acts in fr. 2 to 6 hours; after 
effect constipating. Do not prescribe it during menstrua- 
tion or pregnancy. 

Toxic Effect: not poisonous but may be vomited. 

Dose: fr. \ to 2 ozs. or more (15 to 60 c.c). Lemon 
juice or brandy helps to disguise the taste. 

23. Fluidextractum rhamni purshianas. (U. S.) 
" Fl. ext. of cascara sagrada." 

Action: mild laxative. Taste: very bitter. 
Toxic Effect: irritation of bowel. 

Dose: fr. 10 to 30 m. (or 0.6 to 2 c.c.) at bed-time with 
water. 

24. Vaccine virus. 

The living virus of cow-pox is used as a prophylactic 
against small pox. The virus should be fresh, and a 
" take " or lesion of cow-pox is required to confer im- 
munity. 

Admin. 1. Clean skin with soap and water. Antiseptics, 
if used, must be washed off lest they kill the virus. 

2. "When dry, scarify skin very superficially without caus- 



177 

ing bleeding. A needle or any sharp instrument will serve. 

3. Apply virus. After it has dried completely cover the 
spot with a sterile pad and secure it with adhesive plaster. 

4. When the inoculation " has taken " the lesion should 
be bathed with antiseptics and dressed aseptically from 
time to time. Secondary infection and much pain can thus 
be avoided. 

Note. — 'Virus is prepared by health departments nearly 
everywhere and is distributed free to physicians. 

25. Typhoid vaccine. 

A killed culture of typhoid bacilli standardized by count. 
Used for prophylactic inoculation against typhoid (p. 65). 

In general, three doses are given subcut. at intervals of 
a week or ten days as follows: 500 million, 1,000 million, 
and 1,000 million. 

The reaction is seldom severe. There may be fever and 
malaise. 

The interval between injections should not be longer than 
10 days lest anaphylaxis result. 

Inoculation is strongly recommended for persons who 
travel, for nurses, physicians, soldiers and others who may 
be exposed to typhoid infection. 

Note. — Prepared by health departments * and pharma- 
ceutical firms. 

26. Tuberculin. 

Used for diagnostic tests and for treatment in suitable 
cases of tuberculosis. For detailed information see " Early 
Pulmonary Tuberculosis; Diagnosis, Prognosis, and Treat- 
ment," by John B. Hawes 2nd, M.D. (Wm. Wood & Co.) 

There are several kinds of tuberculin. Koch's old tuber- 
culin is a glycerine extract of tubercle bacilli. It is still 
used extensively. 

27. " Normal salt solution." 

Used by hypodermoclysis, intravenously, or by rectum, 
depending upon circumstances and object in view. 

The common solution consists of 0.6% of sodium chloride 
in distilled water. 

Solutions are prepared also according to other formula? 



Distributed free in Massachusetts by the State Board of Health. 



179 

which contain calcium and potassium chloride in addition 
to sodium chloride. 

When prescribing specify formula desired. 

28. Alcoholic beverages. 

A. (a) Spiritus frumenti. (U. S.) "Whiskey." 
(&) Spiritus vini Gallici. (U. S.) "Brandy." 

Uses: 

1. Quickly diffusible stimulant; dose by mouth, fr. 1 

drach. to 1 oz. (or 4 to 30 c.c). Dose subcut, 
30 min. (or 2 c.c). 

2. To promote appetite; best taken with meals and 

well diluted. 

3. As a food in malnutrition when other foods are not 

absorbed in sufficient quantity. Alcohol is espe- 
cially useful in selected cases of typhoid or septic 
infection. 
Dose fr. 1 to 2 oz. (or 30 to 60 c.c.) diluted with water 
and repeated at intervals of fr. 2 to 6 hours. Larger doses 
are sometimes beneficial. 

If odor remains on breath reduce dose or lengthen in- 
terval. 

Champagne is often borne better than whiskey or 
brandy when the stomach is irritable. 

B. Beer, ale, porter, or malt may be prescribed with 
meals to improve appetite and to promote increase of 
weight. 

29 "RUSSIAN OIL" 

Petrolatum liquidum (U. S.) and "Russian Oil" are 
liquid paraffins under the definition of the British Pharma- 
copoeia, but " Russian Oil " is not liquid petrolatum be- 
cause of a difference between Russian and American Pe- 
troleum. " Russian Oil " is more refined than is ordinarily 
the case with liquid petrolatum. The latter usually has a 
yellowish color and an unpleasant taste, but the former 
is colorless and tasteless. 

Substitutes for " Russian Oil " should have similar gen- 
eral characteristics, should be tasteless, and of high specific 
gravity. Lighter oils seem less efficient, and sometimes es- 
cape through the anus involuntarily. 



181 

Action: A lubricant which passes unabsorbed and un- 
digested through the intestine. Unlike olive oil it is not 
a food, and is less apt to disturb the digestion. 

Used chiefly in chronic constipation, alone or in con- 
junction with other forms of treatment. 

Dose from 1 to 3 tablespoonfuls twice daily; preferably 
several hours after a meal. 

30 AGAR-AGAR 

Action: Agar-agar swells tremendously by absorbing 
water, is not digested, and does not ferment in the intes- 
tinal tract. Therefore, it stimulates peristalsis and helps 
to sweep out the bowel. 

Used in chronic constipation, generally in conjunction 
with other forms of treatment. 

Dose from \ to 1 tablespoonful once or twice daily. 

Administration: Powdered agar can be eaten on cereal. 
Granulated agar can be mixed with and washed down with 
milk or water. Agar-agar wafers are more attractive but 
expensive. 

DRUGS VALUABLE FOR OCCASIONAL USE. 

i. Thyroid extract.* 

2. Liquor potassii arsenitis. (U. S.) " Fowler's 

solution.'' 

3. Pilocarpines hydrochloridum. (U. S.) 

4. Apomorphinae hydrochloridum. (U. S.) 

5. Vinum colchici seminis. (U. S.) 

6. Quininae hydrobromidum. (U. S.) 

7. Hyoscinae hydrobromidum (U. S.) f chemically 
Scopolaminae hydrobromidum (U. S.) [the same. 

8. Caffeinae sodio-salicylas. (X. F.) 

9. Oleum tiglii. (U. S.) " Croton oil." 

10. Elaterium. (Br.) 

11. Adrenalin chloride solution,! 1 to 1,000. 



Not official. Burrough's, Welcome & Co.'s extract is good. 
U. S. t. Parks, Davis & Co. 



1S3 

12. Cocainae hydrochloridum. (U. S.) 

13. Atropinae sulphas. (U. S.) 

14. Strophanthinum. (U. S.) * 

15. Apocynum. (U. S.) 

16. Emetine hydrochloride, f 

DRUGS IN COMMON USE. 

1. Tinctura ferri chloridi. (U. S.) 

2. Liquor ferri et ammonii acetatis. (U. S.) 

" Basham's mixture." 

3. Spiritus astheris compositus. (U. S.) 

" Hoffmann's anodyne." 

4. Spiritus ammonias aromaticus. (U. S.) 

5. Potassii bitartras. (U. S.) " Cream of tartar." 

6. Potassii citras. (U. S.) 

7. Pilula scillas composita. (Br.) 

8. Liquor antisepticus alkalinus. (N. F.) 

" Alkaline antiseptic." 

9. Liquor sodii boratis compositus. (N. F.) " Do- 

bell's solution." 

10. Caffeina citrata. (U. S.) 

11. Strychnines sulphas. (U. S.) 

12. Tinctura nucis vomicae. (U. S.) 

13. Syrupus hypophosphitum. (U. S.) 

" Syrup of hypophosphites." 

14. Syrupus hypophosphitum compositus. (U. S.) 

" Compound syrup of hypophosphites." 

15. Phillips 5 Milk of Magnesia.t 

16. Senna. (U. S.) " Senna leaves." 

17. Glycerinum. (U. S.) 

18. Tinctura iodi. (U. S.) 

19. Tinctura belladonnas foliorum. (U. S.) 

20. Pilulas catharticas compositas. (U. S.) 

" Compound Cathartic Pills." 

21. Pilulas aloini, strychninae, et belladonnas. 

(X. F.) "A. S. and B. Pills." 

* Boehringer's is good. 
t Not official. 
t Proprietary. 



185 

WEIGHTS AND MEASURES. 

METRIC SYSTEM. 

1 kilogram (kg.) =1 litre of distilled water at maximum 
density, i.e., at 4° C. and 760 mm. pressure. 

1 kg. = 1000 grams. 

1.0 gm. =gram gm.). 

0.1 gm. = decigram (dg.). 

0.01 gm. = centigram (eg.). 

0.001 gm.= milligram (mg.). 

APOTHECARIES' OR TROY WEIGHT. 

1 grain or gr. = 0.065 gm. 

1 drachm (dr. or drach.) or 5 = 60 grs. or approx. 4 gm. 
1 ounce (oz.) or 5 = 8 dr. = 480 grs. or approx. 30 gm. 
1 pound (lb.) =12 5 or approx. 375 gm. 

U. S. APOTHECARIES' OR WINE MEASURE. 

1 minim (min.) or m. = 0.062 c.c. (or approx. 1 drop of 
water ) . 

1 fl. drachm (drach. or dr.) or 5 = 60 m. or approx. 4 c.c. 
1 fl. ounce* (oz.) or 5 = 8 dr. = 480 m. or approx. 30 c.c. 
1 pint (O) =16 5 or approx. 480 c.c. 



1 fl. oz. of water weighs 455.6 gr; 



